clerkship handbook - University of Hawaii â Department of Medicine

UNIVERSITY OF HAWAII 

JOHN A. BURNS SCHOOL OF MEDICINE 

DEPARTMENT OF MEDICINE 

THIRD-YEAR CLERKSHIP IN 

INTERNAL MEDICINE 

MEDICINE 531 (6B) 

MEDICINE 532 (6L) 

CLERKSHIP HANDBOOK 

Revised 02/25/13 

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TABLE OF CONTENTS 

CONTACT INFORMATION ................................................................................................................................................... 3 

SUMMARY TABLE OF CLERKSHIP REQUIREMENTS ................................................................................................. 4 

TOP 10 WAYS TO EXCEL ON THE INTERNAL MEDICINE CLERKSHIP ................................................................. 5 

DESCRIPTION OF THE THIRD-YEAR CLERKSHIP IN INTERNAL MEDICINE ...................................................... 6 

INTRODUCTION ..................................................................................................................................................................... 6 

Goal of the Clerkship ........................................................................................................................................ 6 

Design of the Clerkship .................................................................................................................................... 6 

Work Hours, Designated Study Time, Days Off and Holidays ..................................................................... 6 

Absences ........................................................................................................................................................... 7 

CURRICULUM ....................................................................................................................................................... 8 

Learning Objectives .......................................................................................................................................... 9 

Learning Strategies .......................................................................................................................................... 9 

EVALUATION IN THE THIRD-YEAR CLERKSHIP IN INTERNAL MEDICINE ..................................................... 9 

General Guidelines ........................................................................................................................................... 9 

Retaking Exams .............................................................................................................................................. 10 

Honors.............................................................................................................................................................. 10 

SPECIFIC REQUIREMENTS AND GUIDELINES................................................................................................ 12 

Inpatient Medicine ........................................................................................................................................... 12 

Ambulatory Medicine ...................................................................................................................................... 16 

PBL Tutorial ..................................................................................................................................................... 18 

Role Descriptions for Medicine 531/532 ....................................................................................................... 19 

MISCELLANEOUS CLERKSHIP INFORMATION ......................................................................................................... 24 

GUIDELINES FOR APPROPRIATE APPEARANCE AND ATTIRE .................................................................... 25 

RECOMMENDED RESOURCES ......................................................................................................................... 26 

REQUIRED EQUIPMENT .................................................................................................................................... 27 

EXPOSURE TO BLOOD/BODY FLUIDS PROTOCOL ....................................................................................... 28 

HIV MEDICINE ..................................................................................................................................................... 29 

MEDICINE T-RES INSTRUCTIONS .................................................................................................................... 32 

STUDENT EVALUATION OF TEACHERS .......................................................................................................... 34 

EVALUATION FORMS ......................................................................................................................................................... 35 

OBSERVED HISTORY AND PHYSICAL ............................................................................................................. 36 

THE BASIC PHYSICAL EXAMINATION SEQUENCE (BPES) ........................................................................... 37 

OBSERVED PATIENT COUNSELING ................................................................................................................ 48 

CASE PRESENTATION ....................................................................................................................................... 49 

SMALL GROUP LEARNING EXPERIENCE ....................................................................................................... 50 

MID-CLEKSHIP FEEDBACK FORM ................................................................................................................... 51 

STUDENT EVALUATION FORM ......................................................................................................................... 52 

OTHER FORMS ...................................................................................................................................................................... 56 

INPATIENT MEDICINE AGREEMENT FORM ..................................................................................................... 57 

INPATIENT WORK HOURS LOG ........................................................................................................................ 59 

PHYSICIAN’S ORDERS ...................................................................................................................................... 60 

APPENDICES .......................................................................................................................................................................... 61 

TRAINING PROBLEMS LIST .............................................................................................................................. 62 

GENERAL CLINICAL CORE COMPETENCIES IN INTERNAL MEDICINE ..................................................... 192 

LIST OF ERROR-PRONE ABBREVIATIONS, SYMBOLS, AND DOSE DESIGNATIONS ............................... 234 

COMPREHENSIVE WRITE-UPS ....................................................................................................................... 238 

Definition of Comprehensive Write-up ....................................................................................................... 238 

Submission Requirements of Comprehensive Write-ups ........................................................................ 238 

Example of Inpatient History and Physical ................................................................................................ 239 

Example of Ambulatory Note ....................................................................................................................... 246 

CLINICAL SKILLS EXAMINATION (CSE) ........................................................................................................ 251 

NBME SUBJECT EXAM IN INTERNAL MEDICINE .......................................................................................... 256 

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CONTACT INFORMATION 

Clerkship Director 

Clerkship Coordinator: 

Hospital Site Coordinators: 

Laurie M. Tam, M.D., F.A.C.P. 

Assistant Professor of Medicine 

1356 Lusitana Street, 7 th Fl., 

Honolulu, HI 96813 

Telephone: (808) 586-7460 FAX: 586-7486 

e-mail: lmtam@hawaii.edu 

Ms. Julieta Rajlevsky 

1356 Lusitana Street, 7 th Fl. 


Telephone: (808) 586-7478 FAX: 586-7486 

e-mail: jlrajlev@hawaii.edu 

Queens Medical Center: 

Miki Kiyokawa, M.D. 


QET9, 1301 Punchbowl Street, 


Telephone: 586-2910 FAX: 586-7486 

e-mail: kmcsitecoordinator@yahoo.com 

Kuakini Medical Center: 

Miki Kiyokawa, M.D. 


Office of Medical Education 

347 N. Kuakini St., Honolulu, HI 96817 

Telephone: 547-9226 FAX: 547-9867 

e-mail: kmcsitecoordinator@yahoo.com 

Tripler Army Medical Center: 

Bethany Sonobe, MD 

Internal Medicine 

Telephone: 433-2638 Pager: 363-1423 

e-mail: bethany.sonobe@amedd.army.mil 

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Third-Year Clerkship in Internal Medicine 

SUMMARY TABLE OF CLERKSHIP REQUIREMENTS 

Inpatient Ambulatory 

1. Call 

a. Every time your team is on call 6B & 6L - 

6B & 6L 

- 

b. Overnight call once (preferably Friday night) 

at KMC 

2. Comprehensive Write-ups 

a. 1 Comprehensive Write-up per week 

6B & 6L 

(3 - 6 total) 

b. 2 Comprehensive Write-ups per week (10 total) 6B 

c. 2 Comprehensive Write-ups per month (10 total) - 6L 

3. Required Clerkship Activities 

a. UH Department of Medicine Grand Rounds 

(designated Tues, 12:30-1:30 pm) 

6B & 6L 

(All students 

except TAMC 

6B 

(All students 

except TAMC) 

b. PBL Tutorial 6B (1x/week) 

6L (1x/week) 

c. Bedside Clinical Skills (1-2x/week) 6B & 6L - 

d. Chief Medical Resident Rounds (1x/week) 6B & 6L - 

e. CVPE (usually Tues pm) 6L 6B 

f. EBM 1 and 2 (usually Wed pm) 6L 6B 

g. EKG Workshop (usually Tues pm) 6L 6B 

h. HIPSTER (Sim Session) 6B & 6L - 

6B (1x/week) 

6L (1x/month) 

i. HIV Medicine (Tues 1:30-5:00 pm) 6L 6B 

j. Neuro 1 and 2 (usually Tues pm) 6L 6B 

k. Site-specific conferences 6B & 6L 6B & 6L 

4. Learning Objectives 

a. Training Problems (33) 6B & 6L 6B & 6L 

b. General Clinical Core Competencies in IM (17) 6B & 6L 6B & 6L 

5. Evaluation 

a. Observed History and Physical (with BPES) 

6B & 6L - 

(by end of 2 nd wk of inpatient) 

b. Observed Patient Counseling (2) 6B & 6L 

c. Mid-Clerkship Feedback Form 6B & 6L 6B & 6L 

d. Student Evaluation Forms 6B & 6L 6B & 6L 

e. Clinical Skills Exam (Saturday, ____________ ) End of Clerkship 

f. NBME Exam (Friday, ____________________) End of Clerkship 

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TOP 10 WAYS TO EXCEL ON THE INTERNAL MEDICINE CLERKSHIP 

1. Find out what your residents and preceptors expect of you. Meet and try to exceed their 

expectations. Follow through on every assigned task. 

2. Be actively involved in the care of your patients to the greatest extent possible. Go the 

extra mile for your patients. You will benefit as much as they will. 

3. Go the extra mile for your team. Additional learning will follow. The more you put in, the 

more you will gain. 

4. Read consistently and deeply about the problems your patients face. Raise what you 

learn in your discussions with your team and in your notes. Educate your team members 

about what you learn whenever possible. 

5. Learn to do excellent presentations as early as possible. This will make you more effective 

in patient care and gain the confidence of your supervisors to allow you more involvement 

in patient care. 

6. Ask good questions. 

7. Speak up—share your thoughts in teaching sessions, share your opinions about your 

patients’ care, constructively discuss how to improve the education you are receiving and 

the systems around you. 

8. Actively seek feedback and reflect on your experiences. 

9. Keep your goals focused on the right priorities, in the following order: patient care, 

learning, and personal satisfaction. You should always strive to meet all three goals. 

10. Always be enthusiastic. Be caring and conscientious and strive to deliver outstanding 

quality to your patients as you learn as much as you can from every experience. 

From: Primer to the Internal Medicine Clerkship, Second Edition, A Guide Produced by the 

Clerkship Directors in Internal Medicine (CDIM), c2008, 2nd edition 

Download free of charge from: 

http://www.im.org/Publications/PhysiciansInTraining/Pages/Primer.aspx 

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DESCRIPTION OF THE THIRD-YEAR CLERKSHIP IN INTERNAL MEDICINE 

INTRODUCTION 

Goal of the Clerkship 

The goal of the Third-Year Clerkship in Internal Medicine is to provide the opportunity to develop 

experience and competence in Internal Medicine, which serves as the foundation for all 

specialties and their respective residencies. To practice competently, a physician must obtain and 

retain a large body of knowledge, master the skills of clinical practice, develop efficient problem 

solving techniques and demonstrate compassion, integrity, self-discipline and life-long learning 

skills. It is the student’s responsibility to utilize this clerkship experience to accomplish these 

goals. It is the Department of Medicine’s responsibility to assure that every graduate of the John 

A. Burns School of Medicine has obtained graduation level competency in Internal Medicine. 

The core of this clerkship is “Patient-Based Learning,” which occurs as students evaluate patients 

through history taking and physical examinations, develop comprehensive assessments including 

appropriate differential diagnoses, formulate diagnostic, therapeutic and education plans and then 

provide care and follow-up appropriate to the inpatient or ambulatory setting. 

Design of the Clerkship 

Third-Year Clerkship in Internal Medicine (MED 531/532) 

MED 531 for 6B students is 11 weeks in length and consists of 5-1/2 or 6 weeks of Inpatient 

Medicine and 5-1/2 or 5 weeks of Ambulatory Medicine. MED 532 for 6L students consists of 6 

weeks of Inpatient Medicine (block) and 25 half days of ambulatory medicine (clinics - one half 

day weekly for 21-22 weeks plus 3-4 additional half days). 

Work Hours, Designated Study Time, Days Off and Holidays 

Work hours 

No student should work more than eighty (80) hours per week, averaged over the course of the 

clerkship. 

The clerkship recognizes that excessive work hours do not promote student well-being and may 

endanger students, their patients and others with whom they interact. 

For inpatient medicine, the earliest time that any student is permitted to arrive at the hospital is 

4:00 a.m. and the earliest time that any student is permitted to see any patient, that is, to actually 

talk to and examine, is 4:30 a.m. (excluding emergency situations such as Code Blues). (See 

Inpatient Medicine) 

The Hospital Site Coordinators and Chief Medical Residents are aware of these work hour 

guidelines. 

If a student is not able to complete his/her work within these work hour guidelines, the student is 

advised to see his/her Hospital Site Coordinator, Chief Medical Resident or Supervising Resident. 

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If a student does not follow these guidelines, the Hospital Site Coordinator and Chief Medical 

Resident are required to advise the student and notify the clerkship. 

It is the clerkship's goal that students will become more efficient with experience, that they will be 

able to arrive at the hospital and see patients at reasonable times and that they will be able to 

maintain reasonable work hours. 

"Designated study time" 

Students should have one (1) afternoon of "designated study time" per week, averaged over 

the course of the clerkship. 

"Designated study time" is defined as time Monday through Friday and morning through 

afternoon away from patient care responsibilities that is devoted to studying which includes 

reading, completing write-ups, preparing for required clerkship activities such as PBL Tutorials, 

Bedside Clinical Skills rounds, Chief Rounds and other inpatient or ambulatory activities. 

Students will have "designated study time" when their patient care responsibilities and any 

required activities are finished. (See Summary Table of Required Medicine Clerkship Activities) 

In both the inpatient and ambulatory settings, students are advised to notify their team and 

preceptor(s), respectively, when they are leaving to study. 

"Designated study time" should be used for educational activities, as described above, and not for 

leisure activities. Therefore, academic action may be initiated against students who abuse the 

"designated study time," as determined by the Department of Medicine Student Education 

Committee. Likewise, inpatient and ambulatory sites that do not follow the guidelines on 

"designated study time" should be brought to the attention of the clerkship director. 

The one day before the NBME Exam is designated a full day of “designated study time” for 

clerkship students. 

Days off 

Students must have one (1) day off per week, averaged over the course of the clerkship. 

On Inpatient Medicine, there is one (1) day off each week, usually a Saturday or a Sunday. The 

day off will be determined by the site’s Hospital Site Coordinator and Chief Medical Resident. 

On Ambulatory Medicine, there are usually two (2) days off each week, usually Saturday and 

Sunday. The days off will be determined by the Ambulatory Preceptor. 

Holidays 

Students will follow the holiday schedule that is observed at their training site. 

Absences 

Absences from Inpatient Medicine 

On each day that you are absent, you must notify your Chief Medical Resident and your Hospital 

Site Coordinator. 

You may be required to make up any time missed. This decision will be made together by your 

Chief Medical Resident, Hospital Site Coordinator and Clerkship Director and is dependent on the 

reason for absence, length of absence, clerkship activities missed and your clerkship 

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performance to date. 

Absences from Ambulatory Medicine 

On each half day that you are absent, you must notify your Ambulatory Preceptor and the Clerkship 

Director (Dr. Laurie Tam at lmtam@hawaii.edu). 

Each half day missed must be made up. 

6B students usually have 2-4 weekday afternoons and every Saturday off each week. They 

should try to schedule their make up during these times, at the convenience of their Ambulatory 

Preceptor. 

6L ambulatory students usually have 3 half days and every Saturday off each week. They should 

try to schedule their make up during these times, at the convenience of their Ambulatory 

Preceptor. 

Notes 

Attendance is mandatory for all Medicine Clerkship orientations and exams. 

If you are absent for more than three (3) days, totaled over the course of the clerkship, the 

clerkship is required to report this to the Office of Student Affairs. 

Required make up for time missed must be completed by the end of Medicine Clerkship in order 

to receive Credit for the clerkship. Ideally, required make up should be completed in the same 

half of the clerkship that time was missed. 

Questions regarding absences should be directed to the Clerkship Director (Dr. Laurie Tam at 

lmtam@hawaii.edu). 

CURRICULUM 

The Medicine Clerkship Curriculum is based on the Clerkship Directors in Internal Medicine 

(CDIM)-Society of General Internal Medicine (SGIM) Core Medicine Clerkship Curriculum 

Guide Version 3.0, which was released in 2006 to all Medicine clerkship directors in the United 

States. The third edition outlines thirty-three (33) Training Problems and seventeen (17) 

General Clinical Core Competencies, which are aligned with the Accreditation Council for 

Graduate Medical Education (ACGME) general competencies. The Training Problems and 

General Clinical Core Competencies are printed in the clerkship’s Student Handbook and 

website. 

The Medicine Clerkship Curriculum, which has been reviewed by JABSOM’s Department 

of Medicine Student Education Committee (SEC), is aligned with and fulfills JABSOM’s 

Graduation Objectives. The curriculum provides third-year medical students with the 

opportunity to develop and demonstrate competence and excellence in the medical 

knowledge, clinical skills and professionalism expected in the evaluation and care of the 

adult patient. 

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Learning Objectives 

a. Training Problems (See Appendix A) 

Appendix B) 

b. General Clinical Core Competencies in Internal Medicine (See 

Learning Strategies 

a. After seeing each patient, students should identify which Training 

Problems were manifested, read and study those Training Problems and assess whether 

they are able to meet the specific learning objectives for each (Appendix A). 

b. Students should read and study the General Clinical Core 

Competencies in Internal Medicine and assess whether they are able to meet the 

specific learning objectives for each (Appendix B). 

c. Students should refer to the Recommended Resources for their 

reading and studying. . 

EVALUATION IN THE THIRD-YEAR CLERKSHIP IN INTERNAL MEDICINE 

General Guidelines 

The clerkship uses a "competency-based" system to assess the three domains of Medical Knowledge, 

Skills and Professionalism. 

For Medical Knowledge, competency is assessed throughout the clerkship by faculty and resident 

observations of students’ clinical performance. It is also assessed by performance on the NBME 

Subject Examination in Internal Medicine administered at the end of the clerkship 

For Clinical Skills, competency is assessed throughout the clerkship by faculty and resident 

observations of students’ clinical performance. It is also assessed by performance on the Clinical 

Skills Exam (CSE) conducted by the Center for Clinical Skills near the end of the clerkship. 

For Professionalism, competency is assessed throughout the clerkship by faculty and resident 

observations of students’ clinical performance. 

a. Hospital Site Coordinators and Ambulatory Preceptors give students mid-clerkship feedback on 

the students’ clinical performance, reviewing the students’ strengths and weaknesses and 

discussing specific strategies to improve. Therefore the clerkship expects students to 

demonstrate improvement in their clinical performance by the end of the clerkship. 

b. The UH Department of Medicine Student Education Committee reviews each student’s entire 

clerkship performance, including Clinical Performance (inpatient and ambulatory), CSE and 

NBME Exam to determine each student’s grade. 

c. The clerkship does not use numerical formulas for evaluation and grading. 

d. For questions about clerkship grades, refer to JABSOM’s Academic Appeals Policy. 

9

Credit 

a. To earn Credit for the Third-Year Clerkship in Internal Medicine (MED 531 for 6B students; 

MED 532 for 6L students), students must demonstrate Clerkship Level Competency in all three 

domains, as reflected by their Clinical Performance (inpatient and ambulatory), CSE and NBME 

Exam. 

For Clinical Performance (inpatient and ambulatory rotations), students need to receive ratings of 

Competent or higher. 

On the CSE, students need to score 55 or higher. 

On the NBME Exam, students need to score 60 or higher. 

Students who do not demonstrate Clerkship Level Competency in all three domains by the end of 

the clerkship may be required to repeat part or all of the clerkship and/or retake the CSE and/or 

NBME Exam. 

b. To earn Credit for Advanced Medicine (MED 541), which is a JABSOM graduation requirement, 

students must also demonstrate Graduation Level Competency on their CSE and NBME Exam 

by December 31 of the fourth year. 

On the CSE, students need to score 60 or higher. 

On the NBME Exam, students need to score 67 or higher. 

Students who do not demonstrate Graduation Level Competency on their CSE and/or NBME 

Exam by the end of the clerkship will be required to retake the respective exam. They may also 

be required to complete a designated fourth-year Medicine elective before retaking the exam. 

Retaking Exams 

CSE 

Students who score 55-59 on their CSE must retake the CSE and score 60 (Graduation Level 

Competency) or higher by December 31 of their fourth year. Students will have up to two (2) 

opportunities to achieve this. 

NBME Exam 

Students who score 60 - 66 on their NBME Exam must retake the NBME Exam and score 67 

(Graduation Level Competency) or higher by December 31 of their fourth year. Students will have up 

to two (2) opportunities to achieve this. 

Honors 

The Department of Medicine gives all students the opportunity to earn an "Honors" grade for exceptional 

performance in the Third-Year Clerkship in Internal Medicine. 

To earn Honors for the Third-Year Clerkship in Internal Medicine (MED 531 for 6B students; MED 

532 for 6L students), students must demonstrate mostly Exceptional performance in all three domains, 

as reflected by their Clinical Performance (inpatient and ambulatory), CSE and NBME Exam by the end 

of the clerkship. 

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SUMMARY OF EVALUATION 

1. Medical Knowledge: 

o Clinical performance (Student Evaluation Form) 

(Interns, Residents, Chief Resident, Inpatient and Ambulatory Attendings) 

Credit for Credit for 

Clerkship Advanced Medicine 

Competency (in 3 rd yr) (by 12/31 of 4 th yr) Consequence 

- - - Repeat the clerkship, 

partially or entirely 

Clerkship Level + + 

o NBME Subject Exam in Internal Medicine (Shelf Exam) 


NBME Clerkship Advanced Medicine 

Score Competency (in 3 rd yr) (by 12/31 of 4 th yr) Consequence 

3. Professionalism: 

o Clinical performance (reflected on Student Evaluation Form) 

(Interns, Residents, Chief Resident, Inpatient and Ambulatory Attending) 


Clerkship Advanced Medicine 

Competency (in 3 rd yr) (by 12/31 of 4 th yr) Consequence 

- - - Repeat the clerkship, 

partially or entirely 

Clerkship Level + + 

SPECIFIC REQUIREMENTS AND GUIDELINES 

Inpatient Medicine 

Schedule: 

1) For 6B students, Inpatient Medicine is 5-1/2 weeks (if in the first half of the academic year) or 6 

weeks (if in the second half of the academic year). 

2) For 6L students, Inpatient Medicine is 6 weeks. 

Site: The student will be assigned to Kuakini Medical Center (KMC), Queen’s Medical Center 

(QMC) or Tripler Army Medical Center (TAMC). 

Orientation: The student will be oriented to the site by its Hospital Site Coordinator(s) (HSC) and 

Chief Medical Resident (CMR). 

Team Assignment: The student will be assigned to a medical team where an Upper Level 

Resident will be directly responsible for the student’s supervision. The student will also work with 

the Intern(s) on the team. 

Call: 

1) Students must take call every day that their team is on call. Students may leave earlier if 

their patient care responsibilities are complete, with the Upper Level Resident’s approval. 

2) Students at KMC must take one (1) overnight call with their team, preferably a Friday night 

or a Saturday night. 

Work Hours (See Work Hours, Dedicated Study Time and Days Off): 

1) The earliest time that students are permitted to arrive at the hospital is 4:00 a.m. at KMC 

and 5:00 a.m. at QMC and TAMC. 

2) The earliest time that students are permitted to see patients, that is, to actually talk to and 

examine patients, is 4:30 a.m. at KMC and 5:30 a.m. at QMC and TAMC (excluding emergency 

situations such as Code Blues). 

3) The Hospital Site Coordinators, Chief Medical Residents and Upper Level Residents are 

aware of these work hour guidelines. If a student is not able to complete his/her work within 

these work hour guidelines, the student is advised to see his/her Hospital Site Coordinator, Chief 

12

Medical Resident or Upper Level Resident. If a student does not follow these work hour 

guidelines, the Hospital Site Coordinator, Chief Medical Resident or Upper Level Resident are 

required to advise the student and notify the clerkship. 

Patient Assignment: 

1) The Upper Level Resident will be responsible for assigning patients to the student. 

Patients should be selected for their ability to cooperate and communicate, as well as for their 

specific medical problems. 

2) The student has a list of Training Problems on which the Third-Year Clerkship in Internal 

Medicine curriculum and specific learning objectives are based. The student’s goal is to see at 

least one (1) inpatient patient with each of thirty-two (32) Training Problems. Note that the Training 

Problem does not have to be the patient’s Chief Complaint. In fact, a patient may present with many 

Training Problems. (See Training Problems section) 

Patient Census: The student should admit 1 – 2 patients per call. The student should actively 

follow an average of two (2) patients at all times (maximum 5 patients). 

Patient Care Responsibilities: 

1) The student should complete an Initial History and Physical on each and every patient 

assigned to the student, whether or not the student was present for the patient’s admission (i.e. 

transfer patients, etc). This Initial History and Physical includes interviewing and examining 

patients either independently or while being observed by a resident or attending. If the student 

observes a resident or attending obtain the History and Physical, this observation does not qualify as 

the student’s own History and Physical. The student would have to go back at another time and 

perform his/her own independent History and Physical “Group” work-ups are not allowed or 

accepted. 

2) The student should perform the physical exam which was taught as the Basic Physical 

Exam Sequence (BPES) in the pre-clinical years. Note that the funduscopic exam is included in the 

BPES. The student will also be expected to perform appropriate Branch Steps as needed. The 

Upper Level Resident is responsible for insuring proper supervision of the following parts of the 

physical exam which may be performed by the student if clinically indicated: female breast exam, 

female genital and/or pelvic exam, male genital and/or prostate exam, and female and male 

rectal exam. This means that the student must be supervised by a physician (interns, upper level 

residents, chief residents or attendings) who is certified or has expertise to competently perform the 

exam in question. 

4) The student is expected to Pre-Round and write daily Progress Notes on all his/her 

assigned patients before the Intern or Upper Level Resident(s) write their note(s). The Intern or 

Upper Level Resident should review the notes with the student, give constructive feedback and 

countersign the notes. Any missed history or physical exam finding should be noted, corrected and 

demonstrated as needed. 

5) The student should Round with the team. Since the student will be expected to have 

detailed knowledge of his/her assigned patients, the student is expected to take the lead in 

discussing his/her patients, including the student’s assessment of the patients’ problems and 

the student’s plans. In addition, the student will be expected to have a general knowledge of the 

other patients on the team so that he/she can be included in the team’s discussions of the care of 

13

all of the team’s patients and can assist the team in the care of all of the team’s patients. The 

student will be expected to actively participate in teaching attending rounds with the team. 

6) The student is expected to assume as much patient care responsibility and functions 

as the team feels are appropriate for the individual student’s level of training and competence. 

The student is expected to participate in patient education and counseling, work with nursing 

staff, dieticians, respiratory therapists, physical and occupational therapists, social workers, 

hospital chaplains, etc. and to assist in discharge planning. 

7) The student may perform Procedures or assist in the performance of procedures that the 

team feels are appropriate for the student’s level of training and competence. The Upper Level 

Resident is responsible for insuring proper supervision of any procedure performed or assisted by 

the student. This means that the student must be supervised by a physician who is certified or has 

expertise to competently perform the procedure in question, which includes interns, upper level 

residents, chief residents or attendings. Note that there are no required procedures for third-year 

medical students to perform. 

8) The student should learn how to write Orders on his/her assigned patients. The student will 

observe the residents enter orders electronically. The student should practice writing orders in their 

Comprehensive Write-ups and daily Progress Notes (in the Plans section) and on the Physician's 

Orders forms (See Physician’s Orders). The Hospital Site Coordinator and residents should 

review the student’s orders with the student and correct them as needed. 

Comprehensive Write-ups: 

1) The student is required to submit 3 write-ups by halfway through the inpatient rotation 

(averaging 1 write-up each week - schedule to be determined by the Hospital Site Coordinator). 

The HSC will decide whether these 3 write-ups are satisfactory. If they are deemed satisfactory, 

then the student will not be required to submit any more write-ups. If, however, they are deemed 

unsatisfactory, then the student will be required to submit 1 – 3 additional write-ups, as 

determined by the Hospital Site Coordinator, up to a maximum of 6 write-ups. (See Appendix) 

2) The HSC should read and then review each comprehensive write-up with the student and 

give constructive feedback. 

3) At the end of Inpatient Medicine, the student will turn in a total of 3 - 6 comprehensive 

write-ups, (total number to be determined by the HSC), either the originals or copies of the originals 

with the HSC’s comments, to the clerkship office. 

Required Clerkship Activities specific to Inpatient Medicine: 

1) Bedside Clinical Skills 

week. 

a) All students on Inpatient Medicine will attend Bedside Clinical Skills 1 - 2 times each 

b) Each week, one student will prepare and formally present one of his/her patients. 

c) Patients should be chosen who are unknown to the other students in the group (ideally) 

and who have physical exam findings. 

d) The student who is presenting should have the case presentation memorized 

(written notes for referral only). 

14

e) After presenting the case, the student will take the group to see the patient. (The 

student should have already gotten the patient’s consent and determined that the patient would 

be available for bedside teaching.) 

f) The Bedside Clinical Skills attending will teach/review physical exam skills and 

review/clarify important physical exam findings. 

g) The Bedside Clinical Skills attending may meet individually with the student who 

presented to give constructive feedback on his/her case presentation. (See Case Presentation 

Evaluation Form) 

h) The Bedside Clinical Skills attending may use the Small Group Learning Experience 

Evaluation Form to evaluate the students in the group. (See Small Group Learning 

Experience Evaluation Form) 

2) Chief Medical Resident Rounds 

a) All students on Inpatient Medicine will attend weekly Chiefs Rounds with the Chief 

Medical Resident (CMR). These may include bedside or didactic teaching. 

b) Chief Rounds give the students the opportunity to specify which areas in Internal 

Medicine they would like the CMR to teach in a small group setting. 

c) The CMR, together with the Upper Level Resident, are responsible for insuring that 

students are instructed in, but not limited to, the following: 

o Case presentations 

o Interpretation of basic EKGs 

o Interpretation of common imaging, including chest and abdominal x-rays and 

CT, head CT and MRI 

o Physiology and management of fluids and electrolytes 

o Interpretation of arterial blood gases 

o Basic physiology and management of shock 

o Basic understanding and management of ventilators (at KMC) 

d) The CMR may use the Small Group Learning Experience valuation Form to evaluate 

the students in the group. (See Small Group Learning Experience Evaluation Form) 

3) HIPSTER (Hawaii InterProfessional Simulation Training for Emergency 

Response) 

Evaluation and Feedback to Students: 

1) The student is expected to regularly (at least once a week) ask for feedback on his/her 

performance and progress from his/her residents and attendings. It is especially important that 

this occurs before the student rotates off the team and before the residents and attendings rotate 

off the team. This feedback should identify the student’s strengths and weaknesses so that the 

student will know what to work on improving. 

2) Midway through Inpatient Medicine, the Hospital Site Coordinator will complete a Mid- 

Clerkship Feedback Form and discuss it with the student. The HSC will indicate whether the 

student’s progress to date is satisfactory or unsatisfactory, identify the student’s strengths and 

weakness and suggest a remediation plan if necessary. (See Mid-Clerkship Feedback Form) 

15

3) Interns, Upper Level Residents and Attendings who work with the student for one (1) week 

or more are expected to evaluate the student. During the course of the student’s inpatient rotation, 

the Intern and Upper Level Resident are expected to give the student verbal feedback on his/her 

performance and progress. This feedback should be provided on a regular basis, ideally daily but at 

least weekly. Then during the last week of the Intern and Upper Level Resident’s block or during the 

last week of the student’s inpatient rotation, the Intern and the Upper Level Resident will complete 

independent evaluations of the student which will be turned in to the Chief Medical Resident or 

Hospital Site Coordinator. Finally, at the end of the student’s inpatient rotation, the HSC will 

summarize all evaluations and complete a summary Student Evaluation Form for the site, which is 

submitted to the clerkship office. (See Student Evaluation Form) 

4) The student will be formally observed performing a history and physical on a patient 

unknown to the student by the end of the student’s second week of Inpatient Medicine. It is the 

student’s responsibility to arrange for a time when both the student and the Chief Medical 

Resident are available. It is the CMR’s responsibility to find an appropriate patient. The CMR will 

observe the student perform a history and physical. The CMR may also ask the student to make 

a brief case presentation. The CMR will complete the Observed History and Physical and 

BPES (Basic Physical Exam Sequence) Evaluation Forms (which should be provided by the 

student to the CMR) and give the student immediate feedback. If the student’s performance is 

not satisfactory, the student must repeat the exercise until his/her performance is satisfactory to 

the CMR. Note that this history and physical may be used for one of the student’s 

comprehensive write-ups. (See Observed History and Physical and BPES Evaluation Forms – 

this is a required clerkship activity.) 

5) The student will have the opportunity to present his/her patients at various hospital rounds 

and conferences. The student should ask the Upper Level Resident or Chief Medical Resident in 

advance for assistance in preparing for such presentations at a level that is appropriate for the 

student’s training and for the particular rounds or conference. After the presentation, the student 

should ask the physician who is supervising the rounds or conference for feedback. (See Case 

Presentation Evaluation Form) 

Ambulatory Medicine 

Schedule: For 6B students, Ambulatory Medicine consists of 5 half days per week for 5-1/2 

weeks (if in the first half of the academic year) or for 5 weeks (if in the second half of the 

academic year). For 6L students, Ambulatory Medicine consists of 25 half days (one half day 

weekly for 21-22 weeks plus 3-4 additional half days). 

Location: The Ambulatory Medicine sites include Queen Emma Clinics, TAMC Internal 

Medicine Clinic, VA Clinics, community health clinics, Kaiser HMO and private physician 

offices. The sites for MED 531 for 6B students are all on Oahu, primarily in Honolulu, 

while the sites for MED 532 for 6L students are either outside of Honolulu on Oahu or on 

the Neighbor Islands. Although each site has unique features, the clerkship’s goal is to 

provide students with a uniform learning experience based on the same learning objectives 

while allowing students the opportunity to take advantage of the strengths of each site. 

Due to the distant location of their assigned sites and their schedules, 6L students 

do not attend any clerkship activities while on Ambulatory Medicine (UH Department of 

Medicine Grand Rounds, EBM 1 and 2, EKG Workshop, HIV Medicine, Neuro 1 and 2). 

16

Patient Assignment: The Ambulatory Preceptor(s) will be responsible for assigning patients 

to the student. Patients should be selected for their ability to cooperate and communicate, as 

well as for their specific medical problems. The student has a list of Training Problems on 

which the Third-Year Clerkship in Internal Medicine curriculum and specific learning 

objectives are based. The student’s goal is to see at least one (1) ambulatory patient with 

each of thirty-three (33) Training Problems. Note that the Training Problem does not have to 

be the patient’s Chief Complaint. In fact, a patient may present with many Training Problems. 

(See Training Problems section) 

Patient Census: The student should work up at least two (2) patients each half day. 

Patient Care Responsibilities: 

1) The student may see new or returning patients for complete examinations or 

problem-focused visits. Ideally, the student will see some of the patients when they return 

for their follow-up visits. 

2) After reviewing the patient’s chart as necessary, the student will perform an 

appropriate history and physical examination. The student will present the case to the 

preceptor who should correct and demonstrate any missed history or physical exam 

findings and review the student’s assessment and plans. 

3) The student will write an appropriate write-up or progress note in a timely manner, as 

specified by the preceptor. The preceptor should review the write-up or note with the student and 

give constructive feedback. 

4) The student is expected to carry out whatever patient care responsibilities and functions 

the preceptor feels is appropriate for the student’s level of training and competence. The student 

should try to assume as much responsibility as is appropriate and possible. The student is 

expected to participate in patient education and counseling, work with office/clinic staff, and to 

assist in follow-up planning. If the student’s patient requires any consultations or procedures, the 

student is highly encouraged to be present if the patient agrees. If the student’s patient is 

hospitalized, the student is highly encouraged to follow the patient during the hospitalization. 

Comprehensive Write-ups: 

1) The 6B student is required to complete an average of two (2) comprehensive writeups 

each week. The 6L student is required to complete an average of two (2) 

comprehensive write-ups each month. These comprehensive write-ups may be different 

from those initially written – they are expected to be more detailed and thorough, requiring 

additional reading and thought. (See Appendix D and E) 

2) The Ambulatory Preceptor should read, correct and review each comprehensive writeup 

with the student and give constructive feedback. 

3) At the end of Ambulatory Medicine, the student will turn in a total of ten (10) 

comprehensive write-ups, either the originals or copies of the originals with the preceptor’s 

comments, to the clerkship office. 

Evaluation and Feedback to Students: 

1) The student is expected to regularly ask the Ambulatory Preceptor for feedback on 

his/her performance and progress, ideally on a weekly basis for 6B students and on a 

monthly basis for 6L students, and definitely before the student finishes Ambulatory 

Medicine. This feedback will give the student the opportunity to correct mistakes and 

17

omissions and to improve skills. 

2) Midway through Ambulatory Medicine, the student should provide the Ambulatory 

Preceptor with a Mid-Clerkship Feedback Form to complete and discuss with the 

student. The preceptor will indicate whether the student’s progress to date is satisfactory 

or unsatisfactory, identify the student’s strengths and weakness and suggest a remediation 

plan if necessary. (See Mid-Clerkship Feedback Form) 

3) At the end of Ambulatory Medicine, the Ambulatory Preceptor will complete a Student 

Evaluation Form provided by the Third-Year Clerkship in internal Medicine. The Student 

Evaluation Form should be completed during the last week of the student’s Ambulatory 

Medicine. The preceptor should review the Student Evaluation Form with the student and the 

student should then sign the form. The form is then submitted to the clerkship office. (See 

Student Evaluation Form) 

4) The student will be formally observed counseling a patient and/or family on two 

separate occasions. (See Observed Patient Counseling Evaluation Form – this is a 

required clerkship activity.) 

PBL Tutorial 

1) All students will attend PBL Tutorial: 

a. Inpatient students, whether 6B or 6L, will attend weekly PBL Tutorial led by 

their Hospital Site Coordinator who serves as the Inpatient PBL Tutor. 

b. Ambulatory 6B students will attend weekly PBL Tutorial led by an Ambulatory 

PBL Tutor. 

c. Ambulatory 6L students will attend monthly PBL Tutorial led by an 

Ambulatory PBL Tutor. 

2) One student will prepare and formally present one of his/her patients at each PBL 

Tutorial. 

3) Patients should ideally be chosen who are unknown to the other students in the 

tutorial group and who manifest one or more Training Problems (see Appendix A). 

4) The student who is presenting should have the case presentation memorized 

(written notes for referral only) and should bring and be familiar with all 

pertinent data (labs, pathology reports, EKG, imaging, etc.). 

6) The group will agree on appropriate Learning Issues that ideally address Training 

Problems and their specific Learning Objectives. (See Appendix A) 

7) At the following week’s PBL Tutorial, the Learning Issues from the previous week will 

be presented and discussed. 

8) The PBL Tutor should meet individually with the student who presented to give 

constructive feedback on the student’s case presentation. (See Case Presentation 


9) The PBL Tutor may use the Small Group Learning Experience Evaluation Form to 

evaluate the students in the group. (See Small Group Learning Experience 


18

Role Descriptions for Medicine 531/532 

The Bedside Clinical Skills Attending’s Role 

1. The BCS Attending’s role will be to serve as a role model, instructor and facilitator. 

The BCS Attending will make formal rounds. Meetings on the inpatient service will 

be scheduled regularly and this time should be held inviolable. 

2. The BCS Attending will be familiar with and reinforce the method of problem based, 

self-directed learning, as established in Units 1-5. 

3. BCS Attendings will emphasize bedside clinical teaching during their rounds, never 

failing to see the patients that are presented. The Attending will serve as resource 

faculty at the bedside, teaching techniques and demonstrating abnormalities. In 

addition to the general bedside teaching, they are tasked to specifically ensure 

competent student performance of pulmonary and cardiac bedside examination 

skills. 

4. The BCS Attending will be responsible for giving feedback to the student on his/her 

performance after each presentation. Any problems identified will be discussed and 

a plan to (FIX SPACING! remedy difficulties will be constructed. Progress on 

previously identified difficulties will also be discussed. 

5. BCS Attendings will be responsible for evaluation and will serve on the 

Departmental Student Evaluation Committee. 

The Upper Level Resident’s Role 

1. Introduction: 

The upper level resident (Levels 2 or 3) is ultimately responsible for the third-year medical 

student’s experience with the inpatient medical team and should insure that the student has a 

good inpatient experience. At the beginning and throughout the student’s inpatient 

experience, the resident should clarify what is expected of students. 

2. Responsibilities: 

The Upper Level Resident will be responsible for assigning 2-3 patients per week 

for the student work up and continuing care. Patients should be selected for their 

ability to cooperate and communicate, as well as for their specific medical problems. 

The Upper Level Resident will be responsible also for reviewing the student’s write 

ups, for assistance with development of learning issues and for help in execution of 

the learning agenda. 

The Upper Level Resident will "sign off" on the student’s write up, confirming that 

he/she has reviewed the written note and given feedback. 

The Upper Level Resident will confirm that the student is pursuing self-directed 

learning by taking advantage of "Dedicated Learning Time." 

19

The Chief Medical Resident’s Role 


The Chief Medical Resident (CMR) serves as a key faculty resource for the medical 

student on the inpatient service. As supervisor for the medical teams and their 

students, the CMR helps insure a good experience for the students. 


a. The CMR will supervise and assist the Upper Level Resident in the 

inpatient instruction of medical students. They are responsible for insuring 

that students are instructed in, but not limited to, the following: 

o Case presentations 

o Interpretation of basic EKGs 

o Interpretation of common imaging, including chest and abdominal x- 

rays and CT, head CT and MRI 

o Physiology and management of fluids and electrolytes 

o Interpretation of arterial blood gases 

o Basic physiology and management of shock 

o Basic understanding and management of ventilators (at KMC) 

b. The CMR will observe and evaluate student’s Observed History and 

Physical during the student’s first two weeks of inpatient medicine, as 

previously described. 

c. The CMR will lead weekly Chief Rounds with the students as 

previously described 

d. The CMR will regularly discuss each student’s clinical performance 

with the Hospital Site Coordinator. 

The Site Coordinator’s Role 


As a community-based clerkship, the Third-Year Clerkship in Internal Medicine 

utilizes several clinical sites for medical student instruction. A major role of the 

Site Coordinator is to provide students at his/her site with the best possible 

educational experience and to insure that that learning experience is equivalent 

to the educational experience provided at the other sites utilized by the 

clerkship. 

The Site Coordinator is selected for his/her knowledge and experience at the site and 

the ability to work well with physicians, staff and administrators at the site, as well as 

the ability to work well with medical students. The Site Coordinator may be inpatient 

(Hospital Site Coordinator) or ambulatory (Ambulatory Site Coordinator). 

2. Responsibilities of Hospital Site Coordinators and Ambulatory Site 

Coordinators include, but are not limited to: 

a. Selecting qualified faculty to provide a good learning experience for the 

20

student(s) assigned to the site. The site coordinator will serve as a resource for 

the faculty and chief medical resident (CMR) at the site. This includes orienting 

new faculty and CMRs and assisting with faculty development and education 

regarding clerkship curriculum, expectations and goals. 

b. Identifying learning resources at the site that are available for student use (i.e. 

library, photocopying, computer, classrooms, etc.). 

c. Orientating new students, which include scheduling and leading orientations to 

the site and key personnel including faculty, CMR and administrative staff, 

making team/clinic assignments, reviewing clerkship requirements and student 

responsibilities. Orientations should occur on the student’s first day at the 

assigned site. 

d. Evaluating case presentations. (See Case Presentation Evaluation Form) 

e. Evaluating comprehensive write-ups. The Site Coordinator will read students’ 

comprehensive write-ups and give constructive feedback at least on a weekly 

basis. (See Appendix D and E) 

f. Meeting with each student regularly to review the student’s performance and 

progress and to provide feedback. These meetings should also be used to 

review the number and type of patients that students are seeing and their level 

of patient care involvement. (See Training Problems List) Formal meetings 

with each student should be scheduled at least twice during the student’s 

rotation at the assigned site, once midway and once before the last day (ideally 

during the last week). 

g. Completing a Mid-Clerkship Feedback Form, midway through the student’s 

rotation at the assigned site, indicating whether the student’s progress to date is 

satisfactory or unsatisfactory, identifying the student’s strengths and weakness 

and suggesting a remediation plan if necessary. The Site Coordinator will 

review the completed form with the student to allow the student time to improve 

in the identified areas of weakness during the remainder of the rotation. If the 

student’s progress to date is unsatisfactory, the Site Coordinator must 

immediately notify the Clerkship Director who may further discuss the student’s 

performance and possible remediation with the Department of Medicine Student 

Education Committee. (See Mid-Clerkship Feedback Form) 

h. Coordinating the site evaluation of students. The Site Coordinator will 

review the student’s performance with each physician (including Interns, Upper 

Level Residents and Attendings) who worked with the student for one (1) week 

or more and also with any Attendings who worked with the student on a weekly 

basis. The Site Coordinator will collect and review evaluation forms such as the 

Observed History and Physical, Observed Patient Counseling, Case 

Presentations and Small Group Learning Experiences. The Site Coordinator 

will complete a summary Student Evaluation Form for the site at the end of the 

rotation (ideally, during the last week), summarizing all the evaluations including 

his/her own personal evaluation. The Site Coordinator will be careful to insure that 

a single evaluation, incident or conflict will not overshadow a student’s overall 

performance. The Site Coordinator will review the form with the student and 

then submit it to the clerkship office. In addition, the Site Coordinator will complete 

the confidential Honors/AOA Evaluation Form which is not shared with the student 

but is submitted to the clerkship office. If the student’s performance is marginal in 

21

any area(s), the Site Coordinator should immediately notify the Clerkship 

Director who may further discuss the student’s performance and possible 

remediation with the Department of Medicine Student Education Committee. 

(See Student Evaluation Form and Honors/AOA Evaluation Form) 

i. Serving as a member of the Department of Medicine Student Education 

Committee (SEC). The Site Coordinator attends the committee’s monthly 

meetings to act as a spokesperson for the students assigned to his/her site, 

reporting on students’ performance and progress and recommending 

commendation and remediation when appropriate. In addition, SEC members 

participate in the oversight, development and implementation of all of the 

Department of Medicine’s 3 rd and 4 th year clinical rotations. 

j. Monitoring students’ work hours, dedicated study time, days off and 

absences. (See Work Hours, Dedicated Study Time and Days Off section.) 

k. Serving as mediator in the event students encounter problems at their 

assigned site. Problems may include clerkship requirements, clerkship 

performance, absences, mistreatment, harassment and abuse. The Site 

Coordinator should refer significant problems to the Clerkship Director and/or the 

Department of Medicine Student Education Committee. 

3. Additional responsibilities of Hospital Site Coordinators include, but are not 

limited to: 

a. Assisting in Team Assignments - the Hospital Site Coordinator will assist 

the Chief Medical Resident with the assignment of students to medical 

teams. 

b. Leading PBL Tutorial. This should occur on average once a week 

throughout the clerkship and each session should last on average 2 – 3 

hours. (See PBL Tutorial description.) 

c. Insuring that Bedside Clinical Skills occur 1 – 2 times each week and 

Chief Medical Resident Rounds occur 1 time each week and monitoring 

students’ attendance at these as well as at other hospital conferences 

and rounds deemed to be of educational value by the Hospital Site 

Coordinator. 

The Ambulatory Attending’s Role 


The ambulatory attending, or preceptor, is a critical element for student learning in 

Internal Medicine as it is practiced in the ambulatory milieu. Although sometimes 

lacking the drama of inpatient medicine, the outpatient setting offers special skills sets 

in learning and teaching critical thinking, decision making, clinical skills and judgment, 

and patient-physician communication in Internal Medicine 


a) The ambulatory attending/preceptor will serve as a role model for excellence 

in ambulatory primary internal medical practice, to include thoughtful, evidence- 

22

ased health care that is patient focused, comprehensive, and which maximizes 

and restores health, and is preventative. 

b) The attending/preceptor will assign patients for student evaluation that will 

cover the depth and breadth of ambulatory learning issues, as found in the 

Learning Objectives listed under Patient’s Presenting Health issues (Appendix 

A). 

c) The attending/preceptor will monitor and teach data gathering as it applies to 

the clinical focus of ambulatory patient care; this includes appropriate 

consideration of the breadth of patient health issues, rather than a simple focus 

on chief complaint. 

d) The attending/preceptor will model and teach evidence-based problem 

solving as it applies to the ambulatory experience. 

e) The attending/preceptor will critique student write-ups for accuracy, style, 

problem solving and give constructive feedback, by applying the criteria of the 

“comprehensive write-up” and the write-up examples (see Appendix E). 

f) The attending/preceptor will give continuous feedback on student clinical and 

analytical skills, and stimulate his/her intellectual growth. 

g) The ambulatory preceptor will assure completion the “Observation of Patient 

Counseling form for a least 2 separate patient encounters. 

h) The attending/preceptor will evaluate student performance in areas of 

medical knowledge, clinical skills, and professionalism and work habits. 

23

MISCELLANEOUS CLERKSHIP INFORMATION 

24

U.H. John A. Burns School of Medicine 


GUIDELINES FOR APPROPRIATE APPEARANCE AND ATTIRE 

These guidelines are intended to contribute to your overall professional development as students 

in training to become physicians. The Third Year Clerkship in Internal Medicine expects students 

to appear and dress in a professional manner. Some things, such as your appearance and attire, 

which may have been acceptable in college, may no longer be appropriate in our clerkship. Your 

appearance and attire should show respect to faculty, staff, classmates, patients and the general 

public. 

It is recognized that different attire will be necessary for different settings, depending on factors 

such as student activities and responsibilities, training sites, patient and public contact. Student 

attire should always be appropriate and not interfere with the activities and responsibilities 

expected of students. 

General guidelines for all Medicine Clerkship students: 

Students should wear: 

JABSOM name tag with photo ID 

Short white medical coat 

Closed-toe footwear 

Students should maintain an optimum level of personal hygiene and grooming 

Strong odors and fragrances should be avoided 

Clothes, hair, fingernails and footwear should be clean and neat 

Clothing should not be suggestive, revealing or tight-fitting 

Clothing should not have offensive images or language 

Sites-specific (inpatient and ambulatory) guidelines for Medicine Clerkship students: 

Students should adhere to the dress code/policy in place at their training site 

25



RECOMMENDED RESOURCES 

Highly recommended clerkship guidebook: 

Primer to the Internal Medicine Clerkship, Second Edition, A Guide Produced by the Clerkship 

Directors in Internal Medicine (CDIM), c2008, 2nd edition – download free of charge from 

http://www.im.org/Publications/PhysiciansInTraining/Pages/Primer.aspx 

Online resources: 

Internal Medicine Essentials for Clerkship Students - online materials such as photographs, tables, 

screening tools and other instruments – access free of charge at http://www.acponline.org/acp_press/essentials/ 

UpToDate – access available at some training sites 

Textbooks: 

Internal Medicine Essentials for Students, American College of Physicians (ACP) and Clerkship Directors 

in Internal Medicine (CDIM), c2011 – discount offered for ACP student members at 

http://www.im.org/Publications/PhysiciansInTraining/Pages/Essentials.aspx 

Kochar’s Clinical Medicine for Students, Lippincott Williams & Wilkins, c2008, 5 th edition 

Cecil Essentials of Medicine, Elsevier, c2011, 8th edition 

Reference textbooks: 

DeGowin’s Diagnostic Examination, McGraw-Hill, c2008, 9th edition 

Spiral bound books and pocket guides: 

Pocket Medicine, Lippincott Williams & Wilkins, c2010, 4 th edition 

Practical Guide to the Care of the Medical Patient, Elsevier, c2011, 8 th edition 

Washington Manual of Medical Therapeutics, Lippincott Williams & Wilkins, c2010, 33rd edition 

Washington Manual of Outpatient Internal Medicine, Lippincott Williams & Wilkins, c2010, 2nd edition 

The Sanford Guide to Antimicrobial Therapy, c2012, 42nd edition 

Highly recommended self-assessment program: 

MKSAP (Medical Knowledge Self-Assessment Program) for Students 5 (Book and Digital), American 

College of Physicians (ACP) and Clerkship Directors in Internal Medicine (CDIM), c2011 – discount offered for ACP 

student members at http://www.im.org/Publications/PhysiciansInTraining/Pages/MKSAPforStudents.aspx 

26



REQUIRED EQUIPMENT 

1. White coat 

2. JABSOM nametag 

3. Stethoscope 

4. Ophthalmoscope and otoscope 

5. Penlight 

6. Reflex hammer 

7. Tuning fork 128 Hz for vibratory exam 

8. Tape measure 

9. Visual acuity card 

10. Small magnifier lens 

11. Disposable tongue blades 

12. Cotton-tipped swabs for sensory exam 

13. Watch with second and minute marks to record vital signs, etc. 

All of the above listed equipment, except for the JABSOM nametag and watch, are available for 

purchase at the Medical Bookstore. 

Students are expected to have ALL of the equipment and to bring them to their assigned training 

sites on the first day. The equipment should be easily and quickly accessible, i.e. worn, carried in 

a bag or in/on a white coat. 

All students on inpatient medicine are required to carry ALL of the listed equipment AT ALL 

TIMES while on the wards. 

Students on ambulatory medicine may find that their assigned sites may have some, but not all, 

of the listed equipment available for student use. If the listed equipment are NOT easily and 

quickly accessible at the site, it is the student’s responsibility to carry them AT ALL TIMES. 

The possible consequences of not having the required equipment are (1) being immediately sent 

to the medical bookstore to purchase them (requiring the student to make up the missed time) 

and (2) receiving unsatisfactory evaluations in the areas of (a) Clinical Skills - physical 

examinations and (b) Professionalism dependability, professional appearance and attire. 

27

EXPOSURE TO BLOOD/BODY FLUIDS PROTOCOL 

1. IMMEDIATELY following the exposure: 

a. Flush the exposed skin or mucous membrane with water or saline. 

If exposure to the eyes has occurred, use wash station or nearest sink to flush eyes with water for at 

least 5 minutes. 

b. Wash any needle stick, puncture, cut or abrasion with soap and water. 

2. Initiate the host agency protocol for hazardous exposure to blood/body fluids by following the instructions outlined in 

the table below. 

3. If the exposure is in a non-hospital setting (for example, ambulatory site not associated with a hospital, in a JABSOM 

lab, class, or other non-hospital-based exposure), you or your preceptor/supervisor can call Queens ED (547-4311) 

to review current protocol for immediate needs in such a circumstance, and begin the process, (AFTER #1). You 

may go to an Emergency Department, or during open hours, contact the University Health Services (Manoa 

Campus) 956-8965, and ask for immediate attention. 

FACILITY CONTACT or GO TO PHONE 

Castle Medical Center Report incident to supervisor. Obtain care from 

Employee Health Coordinator or hospital supervisor who 

will assist in filing incident report. Contact JABSOM 

OSA to report incident. 

263-5159 or 

hospital supervisor 

263-5329 

(5 pm-8 am) 

HOME Clinic 

Notify attending physician and complete incident report. 221-0685 

Kaiser Permanente Medical 

Center 

Kapiolani Medical Center 

Kuakini Medical Center 

Pali Momi Medical Center 

Call Dr. Jill Omori to report exposure. 

Report incident within 2 hours of exposure. Call 

operator in house “0” and ask for infection control 

personnel on duty. 

Report to Employee Health. Go to Emergency Dept, if 

EH closed, also call on-call Employee Health 

Coordinator, 983-6000). 

Occupational Health Services. 

When closed, go to ED, and also notify Nursing 

Supervisor (through Operator, dial “O”). 

Employee Health during regular work hours or 

Emergency Department when exposure occurs after 

hours. Notify supervisor. Report incident Work Injury 

Line. 

432-0000 

983-8525 

547-9531 

535-7200 

The Queen’s Medical Center Employee Health/PEP Team. 547-4004 

Straub Clinic and Hospital Employee Health during business hours, go directly to 522-3481 

ED after business hours. 

Tripler Army Medical Center Let care team know of exposure. Report to the ER. 

Report exposure to, or go to, Occupational Health the 

next business day. 

433-6235 

VA Clinic 

Contact EHU during business hours. Go to TAMC ER 

after hours. 

433-0091 

Wahiawa General Hospital 

Go to ER; also notify Nursing Supervisor (through 

operator) of exposure. 

621-4230 

You may also seek care and information from University Health Services (956-8965), your personal physician, or any emergency 

department, but seek immediate evaluation and counseling. All follow-up care after immediate evaluation services are the 

responsibility of the student 

4. Report exposure to; 

a. Your supervising faculty member and course/clerkship director 

b. Medical School Office of Student Affairs @ 692-1000; 

c. For URGENT after hours needs, call 692-0912, ask for Dr Smerz or Administrator on-call 

5. Students should be knowledgeable about their health insurance coverage, and should know what their plan will 

cover related to occupational exposures. Remind anyone billing for follow-up that it is NOT an Occupational 

Exposure, but medical follow-up, or the insurer may not want to pay for services. 

JABSOM’s Affiliation Agreement with Health Care Facilities (HCF) state: 

“Environmental exposure. In the event a medical student is exposed to an infectious, environmental, or occupational hazard at 

the HCF, the HCF shall be responsible for providing immediate evaluation and counseling as with employees of the HCF. Followup 

after the initial evaluation and counseling will not be the responsibility of the HCF, and will proceed according to University 

student health policies.” 

28



HIV MEDICINE 

1:30 – 5:00 p.m. 

Clint Spencer Clinic 

Leahi Hospital 

All students in the Third-Year Clerkship in Internal Medicine are scheduled to attend one of the 

upcoming HIV Medicine sessions. 

This is a required clerkship activity. 

How to prepare for the HIV Medicine session: 

1. Read the 4 chapters on HIV at http://uhmed.org/images/HIV_Required_Reading.pdf 

2. Read about the Clint Spencer Clinic at http://www.hawaii.edu/hacrp/spencer.htm 

3. Read about HACRP (Hawaii AIDS Clinical Research Program) at 

http://www.hawaii.edu/hacrp/home2.htm 

4. If you are on inpatient medicine, please notify your team and chief resident of your 

scheduled absence to attend this required clerkship activity. Likewise, you should discuss 

with them whether or not you are expected to return to the hospital after this session. 

What to bring to the HIV Medicine session: 

White coat 

JABSOM nametag 

Temporary parking pass 

After attending the HIV Medicine session: 

Check off HIV as an “S” (Special” patient encounter) on your Training Problems List 

Log patient(s) 

Evaluate teaching attending(s) 

29

Location and Parking: 

The Clint Spencer Clinic is located on the basement floor of the Young Building on the grounds of 

Leahi Hospital at 3675 Kilauea Ave (on the block bordered by Kilauea Ave, Makapuu Ave, 

Maunalei Ave and Pokole St.) in Kaimuki. 

There is free parking in an open lot on Maunalei Ave. You may park in any unmarked stall. (Do 

not park in the stalls marked “Reserved for Clinical Research.”) Display your temporary parking 

pass on your dashboard. 

After parking, cross Maunalei Ave, walk on the main floor (actually the basement floor) of the 

main building (Young Building) and look for a sign that reads “HACRP” (Hawaii AIDS Clinical 

Research Program) and then the door that reads “Clint Spencer Clinic.” Check in with Joel 

Chapman at the reception desk. 

Please plan on arriving early at 1:15 p.m., especially if you are not familiar with Leahi Hospital 

and to allow time for parking. 

If you get lost, call the Clinic at 737-2751. 

30

TEMPORARY 

PARKING PASS 

FOR 

THE CLINT SPENCER 

CLINIC 

Date _______________ 

1:30 – 5:00PM 

CALL 737-2751 for 

QUESTIONS 

31

MEDICINE T-RES INSTRUCTIONS 

General 

Logging all of your patients is required for JABSOM accreditation and for your clerkship grade. 

Failure to log properly and on a timely basis may lead to serious consequences for JABSOM 

and for you. 

You should log your patients regularly – ideally every workday so that you don’t forget and so 

that you don’t fall behind. 

You should sync your patient log regularly – at least once a week. 

T-Res Data Fields 

Complete all data fields (except 2 nd Diag which is not always needed). 

Date: 

In the Inpatient setting, the date is when you first saw the patient. This may or may not be the 

date of admission. 

In the Ambulatory setting, the date is when you see the patient. If you see a patient again for 

a follow-up visit, the patient should be logged again using the date of the follow-up visit. 

Site: 

In the Inpatient setting, select the hospital (KMC, QMC, TAMC) 

In the Ambulatory setting: 

o If you are working in a clinic, select the clinic (QEC, VA, Kaiser-Mapunapuna, Kaiser- 

Waipio, Kalihi Palama, Kokua Kalihi Valley, TAMC Clinic) 

or 

o 

If you are working in a physician’s office, select Medicine – Other Amb (Do not select 

Private Outpatient). 

Do not select Other 

Setting: 

For the Inpatient block: Select Inpatient or Special (Do not select Other) 

Inpatient is the patient for whom you performed a history and physical exam, and wrote daily 

progress notes. In other words, you provided “D” (Direct patient care) to this patient. 

You should log each patient only 1 time during the patient’s hospitalization. For example: If 

Mr. S was hospitalized for three days, although you wrote daily progress notes, you should log 

him only 1 time (upon his admission). If Mr. S. was discharged and then comes back to your 

team, you should log him again as a new patient encounter (upon his re-admission). If, 

however, Mr. S. went home AMA and then comes back with the same problem, you should 

not log him as a new patient encounter. If, however, Mr. S. went home AMA and then comes 

back with a different problem, you should log him as a new patient encounter. 

Special: Special is any patient that contributed to your education in the setting of conferences, 

rounds, procedures, etc. In other words, you did not provide “D” (Direct patient care) to this 

patient. Instead, this was an “S” (Special setting). If you wrote one or two progress notes to 

help out your team (but not on a daily basis), this is still an “S” (Special setting). 

For the Ambulatory block: Select Ambulatory or Special (Do not select Other) 

Ambulatory is the patient for whom you performed a history and physical exam, and wrote a 

note. In other words, you provided “D” (Direct patient care) to this patient. 

Each and every visit, including follow-up visits, should be considered a new patient encounter 

and logged. 

32

Special: Special is any patient that contributed to your education in the setting of 

conferences, rounds, procedures, etc. In other words, you did not provide “D” (Direct patient 

care) to this patient. Instead, this was an “S” (Special setting). 

Supervisor: 

In the Inpatient setting, select last name MEDICINE + first name Inpt-KMC, Inpt-QMC-MTC, 

Inpt-QMC-UHS or Inpt-TAMC. 

In the Ambulatory setting, select the attending physician from the menu - except for the 

following situations: 

o If you are at QEC, select MEDICINE, QEC 

o If you are at TAMC IM Clinic, select MEDICINE, TAMC Clinic 

o If you are at VA Honolulu, select MEDICINE, VA 

o If you are at another VA, select your attending physician 

If the setting is Special, select MEDICINE, Special 

Do not select Other 

Birth Date: 

Enter the patient’s date of birth 

Sex: 

Select the patient’s gender 

Problems: 

Select up to 5 Training Problems that apply to the patient 

If none of the Training Problems apply to the patient, select None 

Prim Diag: 

Select the primary diagnoses that you addressed for this patient. You may enter up to 5 

diagnoses. 

If the diagnosis is not listed or if you have a more specific diagnosis than is listed, you can 

write in the diagnosis by choosing Other. 

2 nd Diag: 

Use this field if the patient has more than 5 diagnoses. You may enter up to 5 additional 

diagnoses, for a total of 10. 

Printed Reports 

Print an activity report according to the following schedule: 

o Mid-inpatient feedback meeting 

o Mid-ambulatory feedback meeting 

o End of the inpatient block 

o End of the ambulatory medicine block 

At the end of the inpatient block and at the end of the ambulatory block, your printed reports 

must reviewed, signed and dated by your Hospital Site Coordinator or Ambulatory Preceptor, 

respectively, and then turned in to the clerkship. 

Your Hospital Site Coordinator or Ambulatory Preceptor may request that you report additional 

handwritten information on your printed report (to help identify patients). However, the signed 

reports that you turn in to the clerkship should be copies without any additional handwritten 

information. 

Instructions for generating and printing your T-Res Medicine Activity Report: 

o Login to the T-Res web site: www.t-res.net 

o Select Lists under Reports in the left column 

o View report 038c – Activity Export Details for Hawaii Pediatrics 

o Activity Type: Internal Medicine, then View Report 

o Select Export as Acrobat (PDF) File 

o You can save a copy if you wish, otherwise select Open, then print the report 

33


Department of Medicine 

STUDENT EVALUATION OF TEACHERS 

Please complete an evaluation on each of the following individuals with whom you interacted during your 

inpatient or ambulatory rotation: 

INPATIENT MEDICINE 

Clerkship Director - Dr. Tam 

Hospital Site Coordinator 

PBL Tutor 

Bedside Clinical Skills Teacher(s) 

Chief Medical Resident 

Upper Levels 

Interns 

CV PE - Dr. Fukuyama 

EBM - Dr. Kasuya 

EKG - Dr. Azuma 

HIV Medicine Teacher(s) 

HIPSTER - Dr. Ganitano 

Neurology - Dr. Yee 

AMBULATORY MEDICINE 

Clerkship Director - Dr. Tam 

Ambulatory Preceptor(s) 

PBL Tutor 

Upper Levels, if at VA 

Interns, if at VA 

CV PE - Dr. Fukuyama 

EBM - Dr. Kasuya 

EKG - Dr. Azuma 

HIV Medicine Teacher(s) 

HIPSTER - Dr. Ganitano 

Neurology - Dr. Yee 

In addition, you are also encouraged to complete evaluations on any other individuals to help the Department of 

Medicine recognize our most outstanding teachers as well as identify those who may need further training to improve 

their teaching. 

These evaluations are anonymous. Your honest and thoughtful feedback is integral in helping the Department of 

Medicine and its teachers improve students’ educational experiences. Your assistance is greatly appreciated. Thank 

you! 

INSTRUCTIONS 

1. Go to uhmed.org/db 

2. Login using the following: Account Name: student 

Password: jabsom*08 

3. Click on “StudentEval” 

4. Select “MS3”, the teacher and the academic year for which you are evaluating 

5. Select “Evaluation of Teacher” 

6. Enter your Block Number which will be emailed to you. 

7. Complete the evaluation form and then click submit. 

8. You will be given a confirmation number and the option to email it to yourself for record keeping (Do not email 

this number directly to Julieta, as she will not be able to identify the sender). Save this confirmation number as 

a proof of your submission. 

9. To complete another evaluation, select “”Email & New Eval”. 

10. Email your confirmation number(s) to Julieta at jlrajlev@hawaii.edu 

34

EVALUATION FORMS 

35



OBSERVED HISTORY AND PHYSICAL 

Evaluation Form 

INSTRUCTIONS: 

o The Observed History and Physical should be scheduled by halfway through the inpatient block. 

o The Chief Medical Resident should select a patient who is unknown to the student. 

o The student must perform the Observed History and Physical by memory. 

o The student should try to finish the Observed History and Physical in 1 hour. 

o The student must turn in at least one (1) completed Observed History and Physical Evaluation Form to the 

Hospital Site Coordinator. 

Student_____________________________________________ Hospital (circle): KMC QMC TAMC 

Start Time ____:____ 

Faculty (Chief Resident) _______________________________ Date_____________ End Time ____:____ 

TOTAL Time ____:____ 

A. PATIENT-PHYSICIAN RELATIONSHIP 

Observe whether and how the student: 

Maximum Score 

Student’s Score 

1. Introduces self to the patient and explains his/her role correctly 2 ( ) 

2. Attends to the patient’s privacy and comfort 3 ( ) before beginning 

and throughout the history and physical 

3. Demonstrates effective listening skills 5 ( ) 

(appropriate use of eye contact, posture, pauses/silence, etc.) 

4. Demonstrates effective verbal skills 5 ( ) 

(appropriate use of open- and closed-ended questions, 

repetition, clarifying, restating, explanation, interpretation, etc.) 

5. Uses language that the patient understands 5 ( ) 

B. INTERVIEW 


1. Obtains the patient’s complete history 5 ( ) 

systematically and completely 

2. Balances allowing the patient to speak while 5 ( ) 

directing questions to efficiently obtain a 

clear and accurate history in the time available 

3. Elicits the history of the present illness (HPI) 10 ( ) 

systematically and completely 

4. Delineates major symptoms systematically and completely 5 ( ) 

(location, radiation, quality, intensity, setting, onset, duration, frequency 

setting, aggravating and alleviating factors, associated manifestations, 

functional impairment, patient’s interpretation of symptoms, etc.) 

36

5. Obtains information for the other major sections of the history 

systematically and completely: 

Maximum Score 

THE BASIC PHYSICAL EXAMINATION SEQUENCE (BPES) 

Student’s 

A. GUIDELINES 

a. Past Medical History (PH) 5 

( ) 

b. M 

During the physical examination, the following guidelines should be observed: 

e 

d 

ications (dose, route, frequency, last dose) 2 ( ) 

c. Allergies (specific reactions and date) 2 ( ) 

d. Family History (FH) 2 ( ) 

e. Social History (SH) 2 ( ) 

f. Substance Use (tobacco, alcohol and Illicit drugs) 2 ( ) 

g. Review of Systems (ROS) 5 ( ) 

C. PHYSICAL EXAMINATION 


1. Demonstrates proper hygienic practices 5 ( ) 

2. Positions the patient and self properly 5 ( ) 

for each part of the physical exam, being 

observant and respectful of the patient’s modesty and comfort 

3. Performs the patient’s complete physical exam 5 ( ) 

systematically, completely and correctly 

4. Performs the basic physical examination sequence (BPES) 10 ( ) 


5. Performs the appropriate branch steps 10 ( ) 


Maximum 

Total Score 

Student’s 

Total Score 

100 ( ) 

If the Student’s Total Score is < 85, 

the Observed History and Physical must be repeated with another patient. 

Comments: 

Chief Medical Resident’s name: _____________________________________ 

Chief Medical Resident’s signature: __________________________________ 

Student’s signature: ______________________________________________ 

I received constructive and immediate feedback on my Observed History and Physical (circle): Yes No 

37

1. The patient always comes first - be considerate of his/her comfort and privacy. 

2. Students WILL wash their hands before each examination. 

3. While the patient must adequately disrobe, modesty should be respected at all times. 

4. The examiner should explain what he/she is doing during the examination. 

5. Never force a procedure on any adult patient. 

6. Reassure the patient during the examination. 

7. Be serious, yet maintain an appropriate sense of humor. 

8. Always be gentle -- a physical examination may be slightly uncomfortable if an 

abnormality is present. It should never be painful. 

9. Be systematic and thorough. 

Physical examination techniques and skills that are required for MD 1 are outlined in 

the MD 1 Handbook and are described in detail below , and in your physical diagnosis 

textbooks. 

B. STEPS OF THE BASIC PHYSICAL EXAMINATION SEQUENCE (BPES) 

These are the steps included in the student Basic Physical Examination Sequence 

(BPES). They should be performed by the student in every complete physical 

examination. The BPES should be completed in 30 minutes. 

Patient sitting: physician facing patient 

1. GENERAL APPEARANCE: Inspect for habitus, level of consciousness, movement, 

comfort, affect. 

2. VITAL SIGNS: Determine body temperature - read thermometer. 

Determine radial pulse - rate per minute and 

compare bilateral radial pulses simultaneously. 

Determine respiratory rate per minute (w hile 

comparing radial pulses). 

Determine blood pressure - place BP cuff 2.5 cm 

above antecubital fossa and at level of atria. 

Determine BP by unilateral palpation of radial pulse 

and then by auscultation of the brachial artery in the 

antecubital fossa. 

3. SKIN: Inspect for overall color, hair and gross lesions. (Inspect and palpate skin in 

detail under each regional exam below). 

4. HEENT: HEAD: Inspect face for symmetry, abnormality. Inspect and 

palpate scalp. 

38

EYES: Test Visual acuity. Check each eye separately (w ith 

corrective lenses) w ith Rosenbaum pocket chart or new sprint. 

Cover opposite eye. Inspect external ocular structures - inspect 

lids, conjunctivae, sclerae, cornea. Test Ocular muscle function 

and alignment (III, IV, VI). Note light reflex in neutral position. Ask 

patient to direct eyes laterally, superiorly and inferiorly " up and 

out," " dow n and out." Test pupillary response in accommodation 

(convergence) and to light (direct and consensual). Inspect 

corneas, lenses, ocular fundi (retina of each eye) w ith 

ophthalmoscope. Stabilize head w ith opposite hand. Ask patient 

to fix gaze on a specific point on the w all. Change hands and 

sides appropriately for examination of the other eye. 

EARS: Test Hearing. Use w ristw atch or w hispered voice. Inspect 

and palpate auricles and mastoids. Inspect canals and tympanic 

membranes on each side. 

NOSE: Palpate for tenderness and ask patient to " sniff" to test 

for patency of each nasal passage. Inspect each passage w ith 

light, using nasal speculum. 

MOUTH: Palpate masseters as you ask patient to " bite dow n" 

(V) bilaterally. Inspect for symmetry as patient " show s teeth" 

(VII) & " protrudes tongue" (XII). Inspect lips, teeth, gingivae, 

oral mucosa, tongue, under tongue, and posterior pharynx w ith 

tongue blade and light. Note uvula motion w hen patient says 

" ah" . 

Patient sitting: physician in front of/behind patient. 

(Tutor to demonstrate both techniques.) 

5. NECK: Inspect neck for neck veins (see below - #7). Inspect and palpate for lymph 

nodes -postauricular, anterior and posterior cervical, submandibular and supraclavicular 

bilaterally, simultaneously with both examining hands. Palpate for parotid glands bilaterally. 

Inspect and palpate for thyroid - each lobe separately, with patient swallowing, and 

palpate for trachea, from front or rear of patient. 

39

6. THORAX: 

POSTERIOR THORAX: Inspect thorax and palpate entire spine. Percuss at costovertebral angles -w ith 

fore-w arning Percuss for diaphragmatic excursion, from mid-thorax dow n to dullness before and after 

deep inspiration on each side. Percuss bilateral chest w all at equivalent areas looking for 

hyperresonance or dullness. Auscultate posterior and lateral lung fields -w ith diaphragm of 

stethoscope, w hile patient is deep-breathing w ith mouth open. Compare side to side in equivalent 

areas. 

Patient sitting: physician facing patient. 

ANTERIOR THORAX: Inspect. Auscultate anterior lung fields beginning w ith supraclavicular areas 

bilaterally w ith deep breathing. 

Patient supine: physician at right. 

AXILLAE: Palpate w ith passive abduction-adduction (R hand for L axilla and 

vice versa). 

BREASTS: Inspect and palpate in all quadrants and nipples bilaterally. 

7. CARDIOVASCULAR: 

NECK: Inspect veins. Palpate carotid pulses on each side one at a time. 

Auscultate carotids bilaterally. 

HEART: Inspect precordium. Palpate apical impulse (PMI) and entire precordium w ith R hand. 

Auscultate w ith diaphragm of stethoscope all cardiac areas (aortic, pulmonic, LSB and apex) w ith 

concurrent left finger palpation of right carotid pulse for time of the heart sounds. Auscultate at 

pulmonic area for split S2 during inspiration. Auscultate at apex w ith bell of stethoscope (supine, 

and in left lateral decubitus position, for presence of S3, S4 and murmur). 

8. ABDOMEN: 

ABDOMEN: Begin by inquiring about pain. Alert patient. Ask patient to flex hips 

and knees to relax abdominal wall muscles. 

40

Inspect. Auscultate - epigastrium, left paraumbilical area over aorta for bruit and 

bowel sounds. Palpate - superficially and deeply in all four quadrants. Palpate deeply 

for aorta and for liver and spleen with deep inspiration. Palpate for spleen: turn 

patient to R lateral decubitus if spleen not previously felt with patient supine. 

INGUINAL AREAS: 

Inspect. Palpate for lymph nodes and/or masses 

and femoral arterial pulses. 

9. EXTREMITIES: 

LOWER EXTREMITIES: 

Inspect and palpate feet, legs, and thighs for 

edema. Palpate dorsalis pedis and posterior tibial 

pulses bilaterally and simultaneously. 

Patient sitting: physician facing patient. 

UPPER EXTREMITIES: Inspect skin, fingernails, and for tremor. Test strength- of grip bilaterally by 

asking patient to squeeze 2 of your fingers. Ask patient to "shrug shoulders" (XI). 

DEEP TENDON REFLEXES: 

plantar reflexes bilaterally. 

Test biceps, triceps, patellar, achilles reflexes and 

Patient standing: physician facing patient and then behind patient. 

POSTURE: 

Inspect for symmetry of shoulders, hips, and 

curvature of the spine. 

LOWER EXTREMITIES: Inspect for varicose veins, other deformities. 

GAIT: Inspect gait as patient walks barefoot. 

The follow ing is usually omitted for the video examination: 

MALE GENITALIA: Inspect penis (ask patient to retract foreskin) and scrotum. 

Palpate scrotal contents and inguinal canals. 

ANORECTUM: Men – have patient bend over examining table or lie in 

left lateral decubitus position w ith right hip and knee flexed. 

Women - patient in dorsosacral position w ith 

knees flexed and abducted (if for pelvic exam), or 

lying in left lateral decubitus position w ith right hip 

and knee flexed. 

Inspect anus, buttocks, and perineum. 

41

Palpate anal canal, rectal ampulla (and prostate in 

men), after gently inserting gloved and lubricated 

index finger. 

PELVIC EXAM: Instruction by obstetrician-gynecologist. 

C. BRANCH STEPS: (EXTENDED PHYSICAL EXAMINATION) 

If an abnormality is detected, it must be fully described and additional examination 

(branch steps) performed to clarify and delineate that finding. 

Example: If decreased auditory acuity is noted, the Weber and Rinne tests must be 

done. 

Such branch steps, how ever, are not part of the BPES. 

Branch steps are taught in separate laboratory sessions. They are useful in further 

elucidating abnormalities uncovered in the history and BPES and are generally not 

screening maneuvers (Refer to page 24). 

42

COMMON ERRORS OF THE BASIC PHYSICAL EXAM SEQUENCE 

EYES: 

When testing visual acuity for each eye corrected preferred, use some form of 

measurement so that your evaluator knows that the same distance is being used for both 

eyes. For most pocket eye-chart cards, the card should be held 14 inches away from the 

eye being tested. 

When testing pupillary responses in accommodation and to light (direct and 

consensual), review the difference between accommodation and convergence. For 

accommodation, ask the patient to look at a distant object or the wall (for example) for 

distance, then have the patient look at your finger held at 2-4 inches from the bridge of his/her 

nose. Convergence should be tested along with ocular motor function testing. 

When inspecting cornea, lens and retina of each eye with ophthalmoscope, remember to 

turn off the room lights. Use your right eye and hold the ophthalmoscope in your right hand when 

examining the patient’s right eye. Conversely, use your left eye and hold the ophthalmoscope in 

your left hand when examining the patient’s left eye. 

EARS: When testing for auditory acuity bilaterally, patient should have their eyes closed. Test 

one ear at a time. Begin by snapping your fingers 3 feet (arms length) away from the ear being 

tested. Ask the patient to indicate if he/she hears the snapping of your fingers. If the patient 

doesn’t hear, move closer to ear in six-inch increments and retest. 

NECK: Inspect and palpate thyroid, each lobe separately, and trachea with swallowing from 

front or back. If you choose to examine the patient from the front, identify the thyroid 

isthmus and then each lobe of the thyroid gland together and separately, asking the patient 

to swallow as you examine each side. 

THORAX: 

Review technique to percuss the lungs, percussing the posterior chest wall in 

symmetrical areas. 

Review proper technique to percuss diaphragmatic excursion on each side. 

Need to estimate the descent of the diaphragm when patient inspires. 

Review proper technique to palpate axillae with passive abduction-adduction. Your left 

hand should be used to examine the patient’s right axillae, using your right hand to support the 

patient’s right arm. Your right hand should be used to examine the patient’s left axillae, using 

your left hand to support the patient’s left arm. 

ABDOMEN: 

Review proper use of hands. Your left hand should be used to support the patient’s left 

flank and your right should be used to feel for the spleen. 

EXTREMITIES: 

Review proper technique to test for deep tendon reflexes, biceps, triceps, knee, ankle, 

and plantar reflexes bilaterally. Student should check patient’s bicep reflexes on each arm then 

tricep reflexes on each arm in order to compare bilaterally versus checking the bicep and tricep 

reflexes on one arm then moving to the other arm and checking the bicep and tricep reflexes. 

When inspecting the spine, please have patient bend over forward in order to check the 

curvature of their spine. 

43

EVALUATION OF PERFORMANCE OF 

BASIC PHYSICAL EXAMINATION SEQUENCE 

Student: Date: _________ Evaluator: ___________________ 

Steps Done Not 

Done 

Seq. 

Incor 

. 

Tech 

. 

Incor 

. 

Comments 

1. General Appearance: (sitting) 

Inspect overall 

2. Vital Signs (sitting) 

A. Temperature with thermometer 

B. Pulse - Measure rate per minute 

Compare bilaterally 

C. Respiratory - rate per minute 

D. Blood pressure - Palpation (unilateral) 

(unilateral) 

- Auscultation 

3. Skin (sitting) 

Inspect overall 

4. HEENT 

A. Head - Inspect face 

Inspect/palpate scalp 

B. Eyes (sitting) 

Test visual acuity for each eye, 

corrected preferred 

Inspect lids, conjunctivae, sclerae, 

corneas 

Test extraocular muscle movements 

and convergence 

Test pupillary responses to light (direct 

and consensual) and to accomodation 

Inspect cornea, lens and retina of each 

eye with ophthalmoscope 

C. Ears (sitting) 

Test for auditory acuity bilaterally 

Inspect and palpate auricles and 

mastoids 

Inspect canals and tympanic 

membranes 

44


Done 

Seq. 

Incor 

. 

Tech 

. 

Incor 

. 

Comments 

D. Nose (sitting) 

Palpate nose and sinuses for 

tenderness 

Test patency of each nasal passage by 

asking patient to "sniff" 

Inspect each nasal passage with 

speculum 

E. Mouth (sitting) 

Test CN V - "bite down" palpate 

masseter 

Examine CN VII - "show teeth" 

Test CN XII - "protrude tongue" 

Inspect lips, teeth, gingivae, tongue, 

posterior pharynx: "say ah" 

5. Neck (sitting) 

Inspect for neck veins (see below also) 

Inspect/palpate for postauricular, cervical, 

sub-mandibular and supraclavicular nodes 

Palpate for parotid gland on each side 

Inspect and palpate thyroid (each lobe 

separately), (and trachea) with swallowing 

6. Thorax (sitting) 

A. Posterior Thorax (sitting) 

Inspect posterior thorax with 

respiration 

Inspect and palpate entire spine 

Percuss costovertebral angles for 

tenderness 

Percuss posterior thorax bilaterally and 

symmetrically 

Percuss diaphragmatic excursion 

bilaterally 

Auscultate posterior lung fields 

bilaterally with deep inspiration 

Auscultate lateral lung fields bilaterally 

B. Anterior Thorax (sitting) 

Inspect anterior thorax with respiration 

45


Done 

Seq. 

Incor 

. 

Tech 

. 

Incor 

. 

Comments 

Auscultate anterior lung fields 

bilaterally (starting with supraclavicular area) 

with deep inspiration 

C. Axillae (supine) Palpate axillae with 

passive abduction- adduction 

D. Breasts (supine) 

Inspect & palpate breasts including 

nipples 

7. Cardiovascular (supine) 

A. Neck Veins/arteries: Inspect, palpate, 

auscultate carotid arteries bilaterally one at a 

time 

B. Heart (supine) Inspect precordium 

Palpate PMI (apical impulse) & 

precordium 

Auscultate with diaphragm at aortic and 

pulmonic areas, LSB and apex 

Auscultate for splitting of S 2 in pulmonic 

area 

left 

Auscultate with bell at apex (supine & 

lateral decubitus) 

8. Abdomen (supine; hips and knees flexed) 

Alert patient to abdominal exam 

Inspect abdomen 

for 

Auscultate epigastrium and over aorta 

bruit, and bowel sounds 

Palpate superficially/deeply in 4 

quadrants 

Palpate for liver 

Palpate for aorta 

Palpate for spleen - supine position 

- R lateral decubitus 

Inspect and palpate for inguinal nodes 

and femoral pulses in inguinal areas 

bilaterally 

9. Extremities 

A. Lower Extremities (supine) 

Inspect and palpate legs and feet for edema 

46


Done 

Seq. 

Incor 

. 

Tech 

. 

Incor 

. 

Comments 

Palpate dorsalis pedis & posterior tibial 

pulses bilaterally 

B. Upper Extremities (sitting) 

Inspect skin and nails. Observe for 

tremor 

Examine grip 

Examine CN XI ("shrug shoulders") 

Test for deep tendon reflexes, biceps, 

triceps, knee, ankle, and plantar 

reflexes bilaterally 

C. Posture (standing) - Inspect spine 

D. Lower Extremities (standing) 

Inspect for varicosities 

E. Gait - Inspect walking 

Did student respect patient's privacy? 

No 

Did student arouse patient's anxiety? 

No 

Yes 

Yes 

Did student display appropriate affect? 

No 

Yes 

Did student use appropriate verbal/nonverbal behavior? Yes 

No 

47



OBSERVED PATIENT COUNSELING 


Complete 2 during ambulatory medicine and turn in to your Ambulatory Preceptor. 

Student: __________________________ Site: ________________ Date: __________ 

Setting: _____ Inpatient 

Counseling was directed at: _____ Patient 

_____ Ambulatory (check one or both) _____ Patient’s family 

Counseling: 

___ Explain diagnoses 

___ Explain tests, procedures or surgery 

___ Review results of tests, procedures or surgery 

___ Review medications (indications, dosing, side effects, etc.) 

___ Review diets, exercise or other lifestyle changes 

___ Discuss smoking cessation 

___ Discuss alcohol use 

___ Discuss compliance (medications, follow-up, etc.) 

___ Review discharge instructions 

___ Other (specify) ___________________________ 

Good 

Needs Improvement 

Student used clear and understandable language. 

Student adapted to patient’s/family’s readiness to learn. 

Student adapted to patient’s/family’s comprehension level 

All pertinent information was presented accurately. 

Student demonstrated empathy and compassion. 

Patient’s/family’s comprehension was assessed. 

Evaluator Comments: 

Evaluator’s name _________________________ 

Evaluator’s signature _______________________ 

Student’s signature _______________________ 

I received constructive feedback on my Observed Patient Counseling (circle): Yes No 

48



CASE PRESENTATION 


Before presenting, the student should give this form to the attending or resident leading rounds. Afterwards, the 

student should turn the form in to the Hospital Site Coordinator. 

Student: _______________________________________ 

Date: _______________ 

Rounds: 

___ Attending Rounds 

___ Bedside Clinical Skills 

___ ICU Rounds 

___ Morning Report 

___ PBL Tutorial 

___ Other Rounds/Conference __________________ 

Major problems/diagnoses of case presented: 

1. ___________________________ 

2. ___________________________ 

3. ___________________________ 

Presentation was clear 

Presentation was organized 

Presentation was memorized 

All pertinent history was presented 

accurately 

All pertinent physical findings were 

presented accurately 

All pertinent labs were presented 

accurately 

All pertinent problems were correctly 

identified 

Assessment was appropriate for level of 

training 

Plan (diagnostic, therapeutic, education) 

was appropriate for level of training 

Comments: 

Exceptional 

Very 

Competent Competent Marginal Unsatisfactory 

Evaluator: 

Print _____________________________ 

Signature _________________________ 

49



SMALL GROUP LEARNING EXPERIENCE 


Student: ____________________ Date: _________ Activity: ____ PBL Tutorial 

____ Bedside Clinical Skills 

____ Chief Rounds 

____ Other: ___________ 

Check appropriate box on this Rating Scale: 

Activity 

Participates actively 

Shares knowledge 

Respects opinions and learning 

needs of others 

Asks thoughtful questions 

Facilitates group process 

Demonstrates appropriate fund 

of knowledge for MS3 

Demonstrates appropriate 

clinical skills for MS 3 

Is properly prepared for this 

activity 

Evaluator Comments: 

Exceptional 

Very 

Competent 

Competent Marginal Unsatisfactory 

Evaluator’s name: ___________________ Evaluator’s signature: _____________________ 

Student’s signature _________________ 

50



MID-CLEKSHIP FEEDBACK FORM 

Student’s name: ___________________________________________________ 

Considering the three domains of Medical Knowledge, Clinical Skills and Professionalism, 

This student’s STRENGTHS are: 

This student NEEDS TO WORK AND IMPROVE ON: 

Overall, this student’s progress to date is: 

___ Satisfactory 

___ Unsatisfactory 

Evaluator’s name: ___________________________ 

Student's signature: __________________________ 

Signature: _____________________________ 

Date reviewed with student: _______________ 

Please make a photocopy of this form after it is completed, reviewed and signed by both the Evaluator and the 

Student. 

Instructions for the Student: 

Keep a photocopy of this form after your Hospital Site Coordinator or Ambulatory Preceptor completes and reviews it with 

you. 

You should actively work on and improve the areas identified above. 

You will be instructed on how to turn in the completed form at the end of your inpatient block and at the end of your 

ambulatory block. 

Instructions for the Evaluator: 

Please keep a copy and include the information in your final Student Evaluation Form. 

Specifically, if you identified any areas to work on and improve, please comment on whether the student successfully 

responded to your feedback and improved by the end of the block. 

51

Exceptional 

Very Competent 

Competent 

Marginal 

Unsatisfactory 

Not Evaluated 

UH John A. Burns School of Medicine 


STUDENT EVALUATION FORM 

Student: _____________________________________ 

Ambulatory Site: _______________________ 

Block: _____ Dates of rotation: _____________________ Date of this report: ___________________ 

IMPORTANT: 

o Comments are MANDATORY for any Exceptional, Marginal or Unsatisfactory ratings. 

 

I. Life-Long Learning Skills 

Graduates will be life-long learners. 

Demonstrates enthusiasm, motivation and self-initiative to learn 

Identifies relevant learning issues, searches for and critically appraises information 

(self-directed learning) 

Comments: 

II. 

The Biological Sciences 

Graduates will understand the biological sciences underlying clinical medicine. 

Demonstrates basic science knowledge (including anatomy, physiology, 

pathology and pathophysiology) 

Demonstrates clinical knowledge (including knowledge of the illnesses seen in the 

adult patient/population in Hawaii, Asia-Pacific region and globally) 

Applies basic science knowledge to clinical situations 

Comments: 

52

Exceptional 


Competent 

Marginal 


Not Evaluated 

 

 

III. The Care of Patients 

Graduates will be able to care for their patients under the supervision of faculty. 

Demonstrates respect and compassion for patients and their families 

Serves as an effective patient advocate 

Interviews patients in a systematic, organized and thorough manner 

(History Taking) 

Examines patients in a systematic, organized and thorough manner 

(Physical Exam) 

Formulates appropriate Assessments, Problem Lists and Differential Diagnoses 

Formulates appropriate Diagnostic Plans 

Formulates appropriate Therapeutic Plans 

Educates and counsels patients (and their families) about their health and 

medical problems 

Demonstrates clinical judgment and problem solving skills 

Works efficiently 

Comments: 

IV. Oral and Written Communication Skills 

Graduates will be able to communicate effectively with patients, families and other 

healthcare providers. 

Uses effective verbal and non-verbal communication skills (including listening 

and using language appropriate for each patient, family and clinical setting) 

Presents cases in a systematic, organized and thorough manner that is accurate 

and appropriate for the clinical setting 

Writes notes (write-ups and progress notes, etc.) in a systematic, organized and 

thorough manner that is accurate, legible and appropriate for the clinical setting 

Comments: 

53

Exceptional 


Competent 

Marginal 


Not Evaluated 

 

V. Professionalism 

Graduates will be professional and ethical, demonstrate an enthusiasm for medicine, and value 

honor, integrity, altruism, respect, accountability, excellence, scholarship, and leadership 

while delivering compassionate care to their patients. 

Demonstrates professional appearance and attire 

Attends all required clerkship and training site-specific activities; is punctual 

Listens attentively and participates actively 

Completes all clerkship and patient care responsibilities on time 

Demonstrates professional behavior 

Demonstrates professional relationships (with attendings, residents, students, 

nurses, other health care workers, patients and their families) 

Seeks, accepts and responds positively and effectively to feedback 

Works as an effective team member 

Comments: 

COMMENTS: 

Ambulatory Preceptor’s name: ___________________________________________ 

Ambulatory Preceptor’s signature: ____________________________ Date: _________________ 

Student’s signature: ______________________________________ 

Date: _________________ 

Please return this form to: 

Julieta Rajlevsky 

UH Department of Medicine 

1356 Lusitana St., 7 th Floor, Honolulu, HI 96813 

Fax: (808) 586-7486 Phone: (808) 586-7478 

54

UNIVERSITY OF HAWAII JOHN A. BURNS SCHOOL OF MEDICINE 

THIRD-YEAR CLERKSHIP IN INTERNAL MEDICINE 

STUDENT EVALUATION FORM 

Ratings Definitions 

EXCEPTIONAL: 

The student consistently demonstrates medical knowledge, clinical skills or professionalism at a level 

higher than expected for a third year student. In other words, the student consistently “goes the extra mile” 

and performs “above and beyond” in the item rated. 

Comments are mandatory for this rating. 

VERY COMPETENT: 

The student on occasion demonstrates medical knowledge, clinical skills or professionalism at a level 

higher than expected for a third year student. In other words, the student on occasion, but not consistently, 

“goes the extra mile” and performs “above and beyond” in the item rated. The student should continue to 

strive for Exceptional ratings. 

COMPETENT: 

The student demonstrates medical knowledge, clinical skills or professionalism at the level expected for a 

third year student. Note that the clerkship expects that most students will receive Competent ratings for the 

majority of items. Some students in the past have incorrectly interpreted Competent ratings as punitive. 

On the contrary, this rating merely indicates that the student performed at the expected level for that 

particular item. The student should continue to strive for Very Competent and Exceptional ratings. 

MARGINAL: 

The student demonstrates medical knowledge, clinical skills or professionalism slightly below the level 

expected for a third year student. An item rated Marginal is an area of weakness that has been identified. 

The student will be expected to work on this area of weakness and demonstrate improvement to the level 

expected for a third year student. A Marginal rating probably precludes an Honors grade. 


UNSATISFACTORY: 

The student demonstrates medical knowledge, clinical skills or professionalism below the level expected 

for a third year student. An item rated Unsatisfactory is an area of weakness that has been identified. 

Formal remediation may be required. An Unsatisfactory rating precludes an Honors grade. 


55

OTHER FORMS 

56



MS3-RESIDENT 

INPATIENT MEDICINE AGREEMENT FORM 

(Revised 8/11/12) 

Name of MS3 _______________________________________________ 

1. The upper level (UL) resident (Level 2 or 3) is responsible for the third-year medical 

student’s inpatient medicine experience. At the beginning and throughout the student’s 

inpatient experience, the UL should clarify what is expected of the student. 

2. The earliest time that the student is permitted to arrive at the hospital is: 

o 4:00 a.m. at Kuakini 

o 5:00 a.m. at Queen’s 

o 5:00 a.m. at Tripler 

The earliest time that the student is permitted to see patients is: 

o 4:30 a.m. at Kuakini 

o 5:30 a.m. at Queen’s 

o 5:30 a.m. at Tripler 

3. The student must take every call with his/her team throughout the inpatient rotation. 

Call at Kuakini: 

The student must take every call (q4) with his/her team throughout the inpatient rotation. 

Overnight Call - 1 required, preferably a Fri night 

If the student is unable to take overnight call on a Fri night, he/she must talk to the 

CMR and the Hospital Site Coordinator about taking overnight call on a Sat instead. 

Call – q4 days until 10 p.m. at the latest 

(May leave earlier depending on admissions and UL approval.) 

Non-Call Days – The student will assist his/her team until after the team signs out. 

Call at Queen’s: 


Overnight Call - none 

Long Call – q4 days until 10 p.m. at the latest 

(May leave earlier depending on admissions and UL approval.) 

Non-Call Days –The student will assist his/her team with admitting patients and may 

leave after team is done with work, with UL approval. 

Call at Tripler: 


Overnight Call - none 

Long Call: 0600 – 1900 q4 days 

Short Call: 0600 – 1600 all other days - The student will assist his/her team until sign 

out. 

4. The UL is responsible for assigning patients to the student (see Training Problems List). 

The student will admit 1 - 2 patients per call. 

The student should actively follow an average of 2 patients at all times (maximum 5). 

57

5. The student must interview and examine patients on his/her own. The student may 

observe the Intern and/or UL obtain the history and physical, but this observation does not 

qualify as the student’s history and physical. 

6. The student must pre-round and write daily Progress Notes on all his/her assigned 

patients before the Intern and/or UL write their notes. The UL should review the 

Progress Notes with the student, give constructive feedback and countersign the note. 

7. The UL is responsible for insuring proper supervision of the following parts of the 

physical exam performed by the student: female breast exams, pelvic exams, rectal 

exams and prostate exams. The supervision must be provided by a physician (such as 

Interns, ULs, Chief Residents or Attendings). 

8. The UL is responsible for insuring proper supervision of any procedure performed 

by the student. The supervision must be provided by a physician (such as Interns, ULs, 

Chief Residents or Attendings) who is certified or has expertise to competently perform 

the procedure in question. Note that there are no required procedures for students. 

9. The UL should assist the student in preparing case presentations at hospital rounds 

or conferences at a level that is appropriate for the student’s training. Whenever a 

student’s patient will be presented, the student is expected to be the one presenting the 

patient (unless it is an ICU patient at Kuakini – then it is up to the CMR and HSC). 

10. The student must have one (1) day off per week, either a Saturday or a Sunday. 

At Kuakini, the day off should be on Sunday - unless the student has call on Sunday, in 

which case the student will take Saturday off. 

11. The student must inform the UL of the student’s activities and whereabouts at all 

times. Specifically, the student must notify the UL whenever leaving the hospital, 

including leaving to attend required 3 rd year or clerkship activities or to study, and should 

discuss if or when he/she needs to return. 

12. When the UL is absent or off, the Intern should assume the UL’s role and 

responsibilities, including all those listed above, in supervising the student. 

13. The Intern and UL should discuss medical student issues and problems with the 

Chief Resident and/or Hospital Site Coordinator as soon as possible. 

1 st Upper Level Resident: 

Name _______________________ Signature ______________________ Date _________ 

(Required by end of MS3’s 1 st week) 

2nd Upper Level Resident: 

Name _______________________ Signature ______________________ Date_________ 

(Required by end of UL’s 1 st week) 

58


INPATIENT WORK HOURS LOG 

Student _____________________________________ 

Inpatient site (circle) KMC QMC TAMC 

Week ___ beginning ____/_____/2012 

On Call? 

Other Activities? 

# New Patients 

(admissions, transfers) 

# Old Patients 

TOTAL # PATIENTS 

For KMC, 

# ICU Patients 

Time In 

Time Out 

TOTAL # HOURS 

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY 

TOTAL # HOURS FOR THE WEEK: _______ 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

o 

Please log your hours daily – otherwise it’s difficult to remember. 

You should log only the hours that you are "working" which includes patient care and required 3 rd year, hospital and clerkship activities such as Colloquia, rounds, conferences, 

PBL Tutorials, Bedside Clinical Skills, Chief Rounds, CV PE, EBM, EKG, HIV Medicine, METS Sim Session, Neuro, etc. 

It's ok to include meals in the middle of your “work day” (as long as it's not a 1 hr lunch!) – it’s too much trouble to clock out for lunch and then clock in afterwards. 

You should not include meals at the hospital before/after your “work day” or reading at the hospital before/after your “work day.” 

You should not include writing your Comprehensive Write-ups and LIs – even if done at the hospital - since that is "home" work. 

You should work no more than 80 hours per week, averaged over the course of the entire clerkship. 

You should have 1 day off per week, usually a Sat or Sun. 

You should follow the holiday schedule observed by your site, since this varies by site. 

On Call? If relevant, please specify Short, Long, or Overnight. 

Other Activities? Please specify off-campus activities. Ex: Colloquia, HIV Medicine, METS Sim Session, etc. 

# Patients is the # of patients (counted at the end of each day) that you are actively following - that is, pre-rounding on, writing notes on and presenting. 

Ask your UL to sign the following Monday _____________________________________________Then turn completed Log in to your CMR/Hospital Site Coordinator. 

59

PHYSICIAN’S ORDERS 

DATE: / / TIME: 

IMPORTANT 

INSTRUCTIONS 

► 1. All orders must be written in metric system 

2. Write with ball point pen only 

SIGNATURE 


SIGNATURE 


SIGNATURE 

60

APPENDICES 

61



TRAINING PROBLEMS LIST 

You are required to see at least one patient with each of the 33 Training Problems during the course of this clerkship. 

This is the minimum requirement. Your goal, however, should be to see at least one inpatient patient and one 

ambulatory patient with each of the Training Problems. The Training Problem does not have to be the patient’s Chief 

Complaint. In fact, a patient may present with many Training Problems. 

Of course, the more patients you see with these Training Problems, the more you will learn. 

Keep track of your patient encounters in the chart below. 

Indicate which encounters involved Direct Patient Care (D) and which encounters did not involve direct patient care, 

referred to as “Special” (S), as in your PDA Patient Log. 

It is your responsibility to insure that you have seen patients with each of the 33 Training Problems by the end of the 

clerkship. You are advised to see your Upper Level Resident, Chief Medical Resident and/or Hospital Site Coordinator 

(when you are on inpatient medicine) or Ambulatory Preceptor (when you are on ambulatory medicine) as soon as 

possible to assist you in finding appropriate patients. 

Please refer to the Student Handbook for the Specific Learning Objectives for each Training Problem. 

Your study of Internal Medicine in this clerkship should be guided by these Training Problems and their Specific Learning 

Objectives. 

Inpatient 

Ambulatory 

-- -- D S 1. Healthy Patient: 

Health promotion, disease prevention and screening 

(i.e. annual or routine physical exam) 

Patients with a symptom, sign or 

lab abnormality (14): 

D S D S 2. Abdominal pain 

D S D S 3. Altered mental status 

D S D S 4. Anemia 

D S D S 5. Back pain 

D S D S 6. Chest pain 

D S D S 7. Cough 

D S D S 8. Dyspnea 

D S D S 9. Dysuria 

D S D S 10. Fever 

D S D S 11. Fluid, electrolyte & acid-base disorders 

D S D S 12. GI bleeding 

D S D S 13. Knee pain 

D S D S 14. Rash 

D S D S 15. Upper respiratory complaints 

62

TRAINING PROBLEMS LIST (continued) 

Inpatient 

Ambulatory 

Patients with a known condition 

(18): 

D S D S 16. Acute MI 

D S D S 17. Acute renal failure & Chronic kidney 

disease 

D S D S 18. Common cancers 

D S D S 19. COPD & Obstructive airways disease 

D S D S 20. Diabetes mellitus 

D S D S 21. Dyslipidemias 

D S D S 22. Heart failure 

D S D S 23. HIV infection 

D S D S 24. Hypertension 

D S D S 25. Liver disease 

D S D S 26. Major depression 

D S D S 27. Nosocomial infections 

D S D S 28. Obesity 

D S D S 29. Pneumonia 

D S D S 30. Rheumatologic problems 

D S D S 31. Smoking cessation 

D S D S 32. Substance abuse 

D S D S 33. Venous thromboembolism 

Complete the Inpatient half of this 2 page chart by your last day of inpatient medicine, including your Hospital Site 

Coordinator’s signature, and then turn in to Julieta Rajlevsky in the Dept of Medicine at UHT 7 th fl. 

Complete the Ambulatory half of this 2 page chart by your last day of ambulatory medicine, including your 

Ambulatory Preceptor’s signature, and then turn in to Julieta Rajlevsky in the Dept of Medicine at UHT 7 th fl. 

Student_____________________________ 

Name 

____________________________ Date____________ 

Signature 

Hospital Site Coordinator____________________ _____________________________ Date____________ 

Name 

Signature 

Ambulatory Preceptor______________________ 

Name 

_____________________________ Date ____________ 

Signature 

63

TRAINING PROBLEM #1: THE HEALTHY PATIENT: HEALTH 

PROMOTION, DISEASE PREVENTION, AND SCREENING 

RATIONALE: 

The growing appreciation for the contributions of screening, prevention, and health promotion to 

health outcomes necessitates that basic clinical education incorporate advances made in this 

area. Especially important are those interventions that relate to prevention of cardiovascular 

disease, the early detection and treatment of potentially curable cancers, and to optimizing care 

for chronic diseases. 

PREREQUISITES: 

Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should include: 

Ability to perform a complete medical history and physical exam. 

Ability to obtain a patient history that includes a family history and an assessment of risk 

factors. 

Knowledge of the warning signs of common cancers. 

Knowledge of basic criteria and principles of health screening. 

Knowledge of clinical epidemiologic concepts as they pertain to estimation of health risk and 

quantitative rationale for screening. 

SPECIFIC LEARNING OBJECTIVES: 

A. KNOWLEDGE: Students should be able to define, describe, and discuss: 

1. The epidemiology and definitions of hypertension, its contribution to cardiovascular risk, the 

impact of treatment on risk, and current. Recommendations for screening. (MK) 

2. The epidemiology of hyperlipidemia, its contribution to cardiovascular risk, the reliability of 

testing modalities, the impact of treatment on cardiovascular risk, and current 

recommendations for screening. (MK) 

3. The epidemiology of common cancers, including: 

Breast cancer, including the efficacy of available screening modalities, impact of early 

treatment on survival, and current recommendations for screening. (MK) 

Common skin cancers, including the warning signs of melanoma and basal and squamous 

cell carcinoma. (MK) 

Cervical cancer, including the utility of the Pap smear, impact of early treatment on 

outcome, and current recommendations for screening.(MK) 

Colorectal cancer, including the utility of available screening methodologies, the impact of 

early treatment on outcome, and current screening recommendations. (MK) 

Prostate cancer, including the utility of available screening modalities, impact of early 

treatment on outcome, and current screening recommendations. (MK) 

4. The risks, benefits, methods, and recommendations for immunizing adults against hepatitis B, 

influenza, pneumococcal infection, tetanus/diphtheria, and mumps/measles/rubella. (MK) 

5. Safe sexual practices and risks, benefits, and efficacy of common methods of contraception. 

(MK) 

6. Efficacy of seat belt use and proper belt application. (MK) 

7. Efficacy of exercise and weight loss in prevention of cardiovascular disease and recommended 

exercise programs. (MK) 

8. The clinical presentations of substance abuse and basic approaches to prevention and 

treatment. (MK) 

64

9. The impact of smoking on cardiovascular and cancer risk and basic approaches to smoking 

cessation. (MK) 

10. Daily caloric, fat, carbohydrate, protein, mineral, and vitamin requirements; adequacy of diets 

in providing such requirements; evidence of need for supplements (e.g. calcium, antioxidants). 

(MK) 

11. The functional status assessment in the geriatric patient and its impact on assuring the best 

possible functional state. (MK) 

12. Common environmental and occupational hazards. (MK) 

13. Controversies and differences that exist in the recommendations for preventive measures and 

screening. (MK) 

B. SKILLS: Students should demonstrate specific skills including: 

1. History-taking skills: Students should be able to obtain, document, and present an ageappropriate 

medical history, including: 

Dietary intake of fats and cholesterol. (PC, CS) 

Exercise and activity levels. (PC, CS) 

Substance use and its effects, including tobacco, alcohol, and elicit drugs. (PC, CS) 

Psychosocial stresses and environmental risks. (PC, CS) 

Specific cancer risks (e.g. family history, exposures, warning symptoms, preventive efforts). 

(PC, CS) 

Any high-risk sexual practices. (PC, CS) 

Immunization status appropriate for adults, including: 

o Diphtheria/tetanus for all adults. (PC, CS) 

o Influenza vaccine and pneumococcal vaccine for the elderly and those with underlying 

chronic disease. (PC, CS) 

o Rubella for sero-negative women of child-bearing age. (PC, CS) 

o Hepatitis B vaccine for medical personnel and other at-risk populations. (PC, CS) 

2. Physical exam skills: Students should be able to perform a physical exam with features 

depending on age/sex/race and medical history of an individual, including: 

Screening skin examination for signs of malignancy. (PC) 

Screening breast examination for a dominant nodule and secondary signs of malignancy. 

(PC) 

Participation in obtaining a Pap smear. (PC) 

Screening rectal examination that includes palpation of the prostate gland, identification of 

any nodules, and performance of a stool test for occult blood. (PC) 

Performance of a functional status examination in the geriatric patient (PC) 

3. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis 

using specific history, physical exam, and laboratory findings identified during the screening 

examination (PC, MK) 

4. Laboratory interpretation: Students should be able to recommend and interpret laboratory 

tests for screening purposes, including consideration of test cost and performance 

characteristics as well as patient preferences. Laboratory and other tests may include, when 

appropriate: 

Complete blood count. (PC, MK) 

Fasting lipid panel. (PC, MK) 

Fasting blood glucose. (PC, MK) 

Urinalysis. (PC, MK) 

65

Stool test for occult blood. (PC, MK) 

Prostate specific antigen. (PC, MK) 

Students should be able to define the indications for and interpret (with consultation) results 

of: 

Mammography. (PC, MK) 

Colonoscopy. (PC, MK) 

Pap smear. (PC, MK) 

Bone densitometry. (PC, MK) 

5. Communication skills: Students should be able to: 

Communicate results of the evaluation and counsel for disease prevention. (PC, CS) 

Elicit questions from the patient and his or her family about the plan. (PC, CS) 

6. Basic and advanced procedural skills: Students should be able to: 

Perform a urinalysis (dipstick and microscopic). (PC) 

Stool occult blood testing. (PC) 

Calculate a BMI. (PC) 

Perform a functional status examination for elderly patients. (PC) 

Administer intramuscular injection of a vaccine. (PC) 

Participate in obtaining a Pap smear. (PC) 

7. Management skills: Students should be able to develop an appropriate evaluation and 

treatment plan for healthy patients, including: 

Designing an appropriate work-up for any abnormalities noted on the screening exam. (PC, 

MK) 

Teaching breast self-examinations. (PC, CS) 

Counseling for: 

o Safe sexual practices. (PC, CS) 

o Seatbelt use. (PC, CS) 

o Healthy diet. (PC, CS) 

o Weight loss. (PC, CS) 

o Practical exercise program appropriate to the patient's age, and current physical 

condition. (PC, CS) 

o Stress management. (PC, CS) 

o Alcohol abstinence. (PC, CS) 

o Smoking cessation. (PC, CS) 

o Cancer screening. (PC, CS) 

o Limiting risks of occupational and environmental hazards. (PC, CS) 

Accessing and utilizing appropriate information systems and resources to help delineate 

issues related to healthy patients. (PC, PLI) 

Using a cost-effective approach based for screening. (PC, SBP) 

Incorporating patient preferences. (PC, P) 

Engaging the patient as an active participant in his/her health care. (PC,P) 

C. ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able to: 

1. Recognize the importance of regularly screening all patients followed and of teaching all 

patients about preventive measures. (PC, P) 

2. Appreciate the necessity of keeping detailed records of screening and health maintenance 

measures. (PC, P) 

3. Understand that physicians and health care delivery organizations are frequently judged by 

their ability to deliver the highest quality screening and preventive measures. (PLI, P, SBP) 

66

4. Recognize the importance of addressing community sources of health risk. (PC, P) 

5. Respond appropriately to patients who are nonadherent preventive measures. (CS, P) 

6. Respect the patient’s right to refuse preventive measures and screening. (P) 

7. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence-based 

considerations in the selection of screening tests. (PLI, P) 

8. Demonstrate ongoing commitment to self-directed learning regarding prevention and 

screening. (PLI, P) 

9. Recognize the importance and demonstrate a commitment to the utilization of other healthcare 

professions in preventative medicine. (P, SBP) 

D. RESOURCES: 

484. 

USPSTF Recommendation: Screening for Breast Cancer 

www.ahcpr.gov/clinic/3rduspstf/breastcancer/brcanrr.htm 

USPSTF Recommendation: Screening for Cervical Cancer 

www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm 

USPSTF Recommendations Statement: Counseling to prevent tobacco use and tobaccocaused 

disease 

www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm 

Screening for Prostate Cancer. American College of Physicians. Ann Int Med 1997; 126: 480- 

Summary of Recommendations for Adult Immunization. Immunization Action Coalition Bulletin. 

Adapted from the recommendations of the Advisory Committee on Immunization Practices 

(ACIP), August 2005 

www.immunize.org/acip 

67

TRAINING PROBLEM #2: ABDOMINAL PAIN 

RATIONALE: 

Abdominal pain is a common symptom that can be attributed to a wide variety of acute and 

chronic disease processes, many of which may represent serious medical problems. Mastery of 

the approach to patients with abdominal pain is important to third year medical students. 


Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should include: 


Ability to communicate with patients of diverse backgrounds. 

Knowledge of gastrointestinal and gynecologic anatomy, physiology, and pathophysiology. 



1. Three principal types of abdominal pain: 

Visceral pain: (MK) 

o Poorly localized but site roughly corresponds to dermatome that innervates the affected 

organ. 

o Characteristics may vary (dull, cramping, burning). 

o Frequently accompanied by secondary autonomic effects (nausea, vomiting, pallor, 

diaphoresis, restlessness). 

o Patient moves around in an attempt to alleviate discomfort. 

Somatoparietal or peritoneal pain: (MK) 

o More localized and more intense than visceral pain. 

o Arises from peritoneal irritation. 

o Aggravated by movement (patient attempts to lie still). 

Referred pain: (MK) 

o Usually well localized but felt in areas remote to affected organ. 

o May be felt in skin or in deeper tissues. 

o Results from convergence of visceral afferent neurons with somatic neurons from 

different anatomic regions. 

2. Relative likelihood of the common causes of abdominal pain based on the pain pattern and the 

quadrant in which the pain is located. (MK) 

3. Diagnostic discrimination between common causes of abdominal pain based on history, 

physical exam, laboratory testing, and imaging procedures. (MK) 

4. Symptoms and signs indicative of an acute/surgical abdomen. (MK) 

5. The influence of age, gender, menopausal status, and immunocompetency on the prevalence 

of different disease processes that may result in abdominal pain. (MK) 

B. SKILLS: Students should be able to demonstrate specific skills, including: 

1. History-taking skills: Students should be able to obtain, document, and present an 

appropriately complete medical history that differentiates among etiologies of disease, 

including: 

• Chronology. (PC, CS) 

68

• Location. (PC, CS) 

• Radiation. (PC, CS) 

• Character. (PC, CS) 

• Intensity. (PC, CS) 

• Duration. (PC, CS) 

• Aggravating or alleviating factors. (PC, CS) 

• Associated symptoms. (PC, CS) 

• Pertinent information about previous abdominal or pelvic surgeries, chronic medical 

conditions, sexual activity, medications, and family history. (PC, CS) 

2. Physical exam skills: Students should be able to perform a focused physical exam in 

patients who present with abdominal pain in order to: 

Establish a preliminary diagnosis of the cause. (PC) 

Assess the severity of the patient’s presenting symptoms and signs(PC) 

Determine the urgency of implementing diagnostic and treatment 

plans. (PC) 

The initial physical examination of the patient should include: 

A general assessment of the patient’s appearance, position, and degree of discomfort. 

(PC) 

Measurement of vital signs, including temperature, pulse, blood pressure, and, when 

indicated, orthostatic blood pressure and pulse. (PC) 

Correct order and technique for examining the abdomen. (PC) 

Inspection of the abdomen for surgical scars, distension, asymmetry or cutaneous 

abnormalities (dilated veins, ecchymoses, etc.). (PC) 

Auscultation of the abdomen for abnormal bowel sounds, bruits. (PC) 

Percussion of the abdomen for detection of hepatomegaly, splenomegaly, abdominal 

masses, or the presence of ascites. (PC) 

Palpation of the abdomen for areas of tenderness, signs of peritoneal inflammation, 

hepatomegaly, splenomegaly, abnormal masses, pulsations, or hernias. (PC) 

Performance of rectal and pelvic exams (under supervision). (PC) 

3. Differential diagnosis: Students should be able to generate a prioritized differential 

diagnosis 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 following diagnoses or conditions: 

Appendicitis. (PC, MK) 

Cholecystitis (biliary colic). (PC, MK) 

Pancreatitis. (PC, MK) 

Diverticulitis. (PC, MK) 

Peptic ulcer disease including perforation. (PC, MK) 

Gastroenteritis. (PC, MK) 

Hepatitis. (PC, MK) 

Irritable bowel syndrome. (PC, MK) 

Small bowel obstruction. (PC, MK) 

Acute mesenteric ischemia. (MK, PC) 

Inflammatory bowel disease. (PC, MK) 

Ruptured abdominal aortic aneurysm. (PC, MK) 

Ureteral stones (renal colic). (PC, MK) 

Pelvic inflammatory disease. (PC, MK) 

69

Ruptured ectopic pregnancy. (PC, MK) 

Abdominal wall pain. (PC, MK) 

Referred pain. (PC, MK) 

4. Laboratory interpretation: Students should be able to interpret specific diagnostic tests 

and procedures that are commonly ordered to evaluate patients who present with 

abdominal pain. Test interpretation should take into account: 

Important differential diagnostic considerations including potential diagnostic 

emergencies. (PC, MK) 

Pre-test and post-test likelihood of disease (probabilistic reasoning). (PC, MK) 

Performance characteristics of individual tests (sensitivity, specificity, positive and 

negative predictive value, likelihood ratios). (PC, MK) 

Laboratory and diagnostic tests should include, when appropriate: 

• CBC with differential. (PC, MK) 

• UA. (PC, MK) 

• Pregnancy test. (PC, MK) 

• Stool for occult blood. (PC, MK) 

• Hepatic function panel. (PC, MK) 

• Amylase and lipase. (PC, MK) 

• Abdominal obstructive series. (PC, MK) 

Students should be able to define the indications for, and interpret (with 

consultation) the results of: 

Abdominal ultrasound. (PC, MK) 

Abdominal CT scan. (PC, MK) 

Paracentesis fluid studies. (PC, MK) 

Upper gastrointestinal endoscopy. (PC, MK) 

Sigmoidoscopy/colonoscopy. (PC, MK) 

Barium contrast studies. (PC, MK) 

Radionuclide scan of the hepatobiliary system. (PC, MK) 


Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient 

and his or her family. (PC, CS) 

Elicit questions from the patient and his or her family about the management plan. (PC, 

CS) 

Communicate in lay terms the indications, risk/benefits, and expected outcomes 

essential to obtaining informed consent for diagnostic and therapeutic procedures 

commonly used to evaluate and treat patients who present with abdominal pain. (PC, 

CS) 


Insert a nasogastric tube. (PC) 

Perform stool occult blood testing. (PC) 

Assist in performing a paracentesis after explaining the procedure to the patient. (PC, 

CS) 

7. Management skills: Students should be able to develop an appropriate 

evaluation and treatment plan for patients that includes: 

Recognizing the role of narcotic analgesics and empiric antibiotics in treating selected 

patients who present with acute abdominal pain. (PC, MK) 

Determining when to consult a gastroenterologist or a surgeon. (PC, SBP) 

Involving a surgeon as soon as possible when a patient is identified as having an acute 

abdomen. (PC, SBP) 

70

Selecting various tests and procedures commonly used to diagnose patients who 

present with symptoms of abdominal pain. ( PC, MK) 

Recommending basic initial management plans for the various causes of abdominal 

pain listed in the differential diagnosis. (PC, MK) 

Considering the potential value of addressing psychosocial issues in the management 

of chronic abdominal pain. (PC, MK) 

Accessing and utilizing appropriate information systems and resources to help 

delineate issues related to abdominal pain. (PC, PLI) 

Using a cost-effective approach based on the differential diagnosis. (PC, SBP) 




considerations in the selection of diagnostic and therapeutic interventions for abdominal 

pain. (PLI, P) 

2. Recognize the importance of patient needs and preferences when selecting among 

diagnostic and therapeutic options for abdominal pain. (P) 

3. Recognize the importance and demonstrate a commitment to the utilization of other 

healthcare professions in the treatment of abdominal pain. (P, SBP) 

D. REFERENCES: 

Silen W. Cope’s Early Diagnosis of the Acute Abdomen. 20 th ed. New York: Oxford 

University Press; 2000. 

Wagner JM, McKinney WP, Carpenter JL. The rational clinical exam. Does this patient 

have appendicitis? JAMA. 1996;276:1589-94. 

Lederle F, Simel D. The rational clinical exam. Does this patient have an abdominal 

aortic aneurysm? JAMA. 1999;281:77-82. 

Trowbridge RL, Rutkowski NK, Shojania KG. The rational clinical exam. Does this 

patient have acute cholecystitis? JAMA. 2003;289: 80-86. 

71

TRAINING PROBLEM #3: ALTERED MENTAL STATUS 

RATIONALE: 

The diagnosis and management of altered mental status requires a working knowledge of all areas of 

internal medicine, so varied are the etiologies and corresponding treatment strategies. Internists must 

master an approach to the problem as they are often the first physicians to see such patients. 


Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should include: 

Ability to perform a complete medical history and physical. 


Basic course work in physiology, pathophysiology, and neuroanatomy. 



1. The differentiation of delirium, dementia, and depression. (MK) 

2. The pathophysiology, symptoms, and signs of the most common and most serious causes of 

altered mental status, including: 

Metabolic causes (e.g. hyper/hyponatremia, hyper/hypoglycemia, hypercalcemia, 

hyper/hypothyroidism, hypoxia/hypercapnea, B12 deficiency, hepatic encephalopathy, 

uremic encephalopathy, drug/alcohol intoxication/withdrawal, and Wernicke’s 

encephalopathy). (MK) 

Structural lesions (e.g. primary or metastatic tumor, intracranial hemorrhage, subdural 

hematoma). (MK) 

Vascular (e.g. cerebrovascular accident, transient ischemic attack, cerebral vasculitis). 

(MK) 

Infectious etiologies (e.g. encephalitis, meningitis, urosepsis, endocarditis, pneumonia, 

cellulites). (MK) 

Seizures/ post-ictal state. (MK) 

Hypertensive encephalopathy. (MK) 

Low perfusion states (e.g. arrhythmias, MI, shock, acute blood loss, severe dehydration). 

(MK) 

Miscellaneous causes (e.g. fecal impaction, postoperative state, sleep deprivation, urinary 

retention). (MK) 

3. The importance of thoroughly reviewing prescription medications over-thecounter drugs, and 

supplements and inquiring about substance abuse. (MK) 

4. The risk factors for developing altered mental status, including: 

Dementia. (MK) 

Advanced age. (MK) 

Substance abuse. (MK) 

Comorbid physical problems such as sleep deprivation, immobility, dehydration, pain, and 

sensory impairment. (MK) 

ICU admission. (MK) 

5. The diagnostic evaluation of altered mental status. (MK) 

6. Indications, contraindications, and complications of lumbar puncture. (MK) 

72

7. Principles of management of the common causes of altered mental status. (MK) 

8. Nonpharmacologic measures to reduce agitation and aggression, including: 

Avoiding the use of physical restraints whenever possible. (MK) 

Using reorientation techniques. (MK) 

Assuring the patient has their devices to correct sensory deficits. (MK) 

Promoting normal sleep and day/night awareness. (MK) 

Preventing dehydration and electrolyte disturbances. (MK) 

Avoiding medications which may worsen delirium whenever possible 

(e.g. anticholinergics, benzodiazepines, etc.). (MK) 

9. The risks of using physical restraints. (MK) 

10. The risk and benefits of using low-dose high potency antipsychotics for delirium associated 

agitation and aggression. (MK) 


1 History-taking skills: Students should be able to obtain, document, and present an ageappropriate 

medical history that differentiates among etiologies of altered mental status including 

eliciting appropriate information from patients and their families regarding the onset, progression, 

associated symptoms, and level of physical and mental disability. (PC, CS) 

2. Physical exam skills: Students should be able to perform a physical exam to establish the 

diagnosis and severity of disease, including: 

Complete neurologic examination. (PC) 

Mental status examination. (PC) 

Fundoscopic examination. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology for 

altered mental status. (PC, MK) 

4. Laboratory interpretation: Students should be able to recommend when to order diagnostic 

and laboratory tests and be able to interpret them, both prior to and after initiating treatment 

based on the differential diagnosis, including consideration of test cost and performance 

characteristics as well as patient preferences. Laboratory and diagnostic tests should include, 

when appropriate: 

CBC with differential. (PC, MK) 

Electrolytes, BUN/Cr, GLC, hepatic function panel, Ca. (PC, MK) 

ABG. (PC, MK) 

Toxicology screen. (PC, MK) 

VDRL. (PC, MK) 

Vitamin B12 and thiamine measurements. (PC, MK) 

Thyroid function tests. (PC, MK) 

Urinalysis and urine culture. (PC, MK) 

Blood cultures. (PC, MK) 

Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell 

counts, staining, cultures, cytology, cryptococcal antigen, VDRL). (PC, MK) 

Students should be able to define the indications for and interpret (with consultation) 

the results of: 

Cranial CT. (PC, MK) 

Cranial MRI. (PC, MK) 

Electroencephalogram. (PC, MK) 

73


Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient and 

his or her family. (PC, CS) 

Elicit questions from the patient and his or her family about the management plan. (PC, CS) 

When the patient is unable to communicate, obtain a history from a collateral source such 

as a family member or other health care proxy. (PC, CS) 


Obtain an ABG. (PC) 

Assist in performing a lumbar puncture after explaining the procedure to the patient. (PC, 

CS) 

7. Management skills: Students should able to develop an appropriate evaluation and 

treatment plan for patients that includes: 

Recognizing that altered mental status in a older inpatient is a medical 

emergency and requires that the patient be evaluated immediately. (PC, MK) 

Writing appropriate fluid and replacement orders for patients with common electrolyte and 

metabolic disturbances. (PC, MK) 

Writing appropriate antibiotic orders for the treatment of common infectious etiologies. (PC, 

MK) 

Ordering appropriate nonpharmacologic and pharmacologic interventions for patients with 

acute altered mental status with accompanying agitation and aggression. (PC, MK) 

Determining when to obtain consultation from a neurologist or neurosurgeon. (PC, SBP) 

Utilizing hospital and community resources for patients with permanent or disabling 

conditions to help assist their transfer back to the community or rehabilitation facility. (PC, 

SBP) 



issues related to altered mental status. (PC, PLI) 



1. Appreciate the family’s concern and at times despair arising from a loved one’s 

development of altered mental status. (CS, P) 

2. Appreciate the patient’s distress and emotional response to that may accompany 

circumstances of altered mental status. (CS,P) 


considerations in the selection diagnostic and therapeutic interventions for altered mental 

status. (PLI, P) 

4. Recognize the importance of patient preferences when selecting among diagnostic 

and therapeutic options for altered mental status. (P) 

5. Demonstrate ongoing commitment to self-directed learning regarding altered mental 

status. (PLI, P) 

6. Appreciate the impact altered mental status has on a patient’s quality of life, wellbeing, 

ability to work, and the family. (P) 

7. Recognize the importance of and demonstrate a commitment to the utilization of 

other healthcare professionals in the diagnosis and treatment of altered mental status. (P, 

SBP) 


74

Ropper AH. (2005). Acute confusional states and coma. In Kasper DL, Braunwald EB, 

Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 

16 th ed. New York, NY: McGraw-Hill; 2005:1624-31. 

Gleason OC. Delirium. Am Fam Physician. 2003;67:1027-34. 

Brown TM, Boyle MF. Delirium. BMJ. 2002;325:644-7. 

Meagher DJ. Delirium: optimizing management. BMJ. 2001;322:144-9. 

75

TRAINING PROBLEM #4: ANEMIA 

RATIONALE: 

Anemia is a common finding, often identified incidentally in asymptomatic patients. It can be a 

manifestation of a serious underlying disease. Distinguishing among the many disorders that cause 

anemia, not all of which require treatment, is an important training problem for third year medical 

students. 


Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should 

include: 



Knowledge of pathogenesis and pathophysiology of anemia. 

Knowledge of the basic biochemistry and pathophysiology of the blood and bone marrow. 

Knowledge of the pharmacology of medications that can cause anemia as well as those used 

to treat it. 



1. Classification of anemia based on red cell size: 

Microcytic: 

o Iron deficiency. (MK) 

o Thalassemic disorders. (MK) 

o Sideroblastic anemia. (MK) 

Normocytic: 

o Acute blood loss. (MK) 

o Hemolysis. (MK) 

o Anemia of chronic disease (e.g. infection, inflammation, malignancy). (MK) 

o Chronic renal insufficiency/erythropoietin deficiency. (MK) 

o Bone marrow suppression (e.g. bone marrow invasion, aplastic anemia). 

o Hypothyroidism. (MK) 

o Testosterone deficiency. (MK) 

o Early presentation of microcytic or macrocytic anemia (e.g. early iron deficiency 

anemia). (MK) 

o Combined presentation of microcytic and macrocytic anemias. (MK) 

Macrocytic: 

o Ethanol abuse. (MK) 

o B12 deficiency. (MK) 

o Folate deficiency. (MK) 

o Drug-induced. (MK) 

o Reticulcytosis. (MK) 

o Liver disease. (MK) 

o Myelodysplastic syndromes. (MK) 

o Hypothyroidism. (MK) 

10. Morphological characteristics, pathophysiology, and relative prevalence of each of the causes 

of anemia. (MK) 

76

11. The meaning and utility of various components of the hemogram (e.g. hemoglobin, hematocrit, 

mean corpuscular volume, and random distribution width). (MK) 

12. The classification of anemia into hypoproliferative and hyperproliferative categories and the 

utility of the reticulocyte count/index. (MK) 

13. The potential usefulness of the white blood cell count and red blood cell count when attempting 

to determine the cause of anemia. (MK) 

14. The diagnostic utility of the various tests for iron deficiency (e.g. serum iron, total iron binding 

capacity, transferrin saturation, ferritin). (MK) 

15. The genetic basis of some forms of anemia. (MK) 

16. Indications, contraindications, and complications of blood transfusion. (MK) 



medical history, that differentiates among etiologies of disease, including: 

Constitutional and systemic symptoms (e.g. fatigue, weight loss). (PC, CS) 

History of gastrointestinal bleeding or risk factors for it. (PC, CS) 

Abdominal pain. (PC, CS) 

Prior history of anemia or other blood diseases. (PC, CS) 

Medications. (PC, CS) 

Diet. (PC, CS) 

Alcohol use. (PC, CS) 

Menstrual history. (PC, CS) 

Family history of anemia or other blood diseases. (PC, CS) 



Pallor (e.g. palms, conjunctiva, nail beds). (PC) 

Mouth (e.g. glossitis, cheilosis). (PC) 

Hyperdynamic precordium, systolic flow murmur. (PC) 

Lymph nodes. (PC) 

spleen. (PC) 

Obtain stool for occult blood testing. (PC) 

Nervous system. (PC) 

3. Differential diagnosis: Students should be able to generate a list of the most important and 

most common causes of anemia, recognizing specific history, physical exam, and laboratory 

findings that suggest a specific etiology. (PC, MK) 



based on the differential diagnosis including consideration of test cost and performance 



Hemoglobin and hematocrit. (PC, MK) 

Red cell indices (e.g. mean corpuscular volume and random distribution width). (PC, MK) 

White blood cell and platelet count. (PC, MK) 

Reticulocyte count. (PC, MK) 

Iron studies (serum iron, TIBC, ferritin, transferrin). (PC, MK) 

Serum B12 and folate. (PC, MK) 

Haptoglobin. (PC, MK) 

77

Lactic dehydrogenase. (LDH) (PC, MK) 

Hemoglobin electrophoresis. (PC, MK) 

Blood smear. (PC, MK) 



Bone marrow biopsy. (PC, MK) 


Communicate the diagnosis, treatment plan, and subsequent follow-up to patients. (PC, 

CS) 

Elicit questions from the patient about the management plan. (PC, CS) 

Counsel with regard to (a) possible causes, (b) appropriate further evaluation to establish 

the diagnosis of an underlying disease, and (c) the impact on the family (genetic 

counseling). (PC, CS) 

6. Basic procedural skills: Students should be able to perform and interpret: 




Evaluating for underlying disease processes, given that anemia is not a disease per se, but 

rather a common finding that requires further delineation in order to identify the underlying 

cause. (PC, MK) 

Prescribing indicated replacement therapy, including iron, vitamin B12, and folic acid. (PC, 

MK) 

Determining when to obtain consultation from a hematologist. (PC, SBP) 



issues related to anemia. (PC, PLI) 



1 Demonstrate commitment to using risk-benefit, cost-benefit, and evidence-based 

considerations in the selection of diagnostic and therapeutic interventions for anemia. (PLI, P) 

2 Respond appropriately to patients who are non-adherent to treatment for anemia. (CS, P) 

3 Demonstrate ongoing commitment to self-directed learning regarding anemia. (PLI, P) 

Appreciate the impact anemia has on a patient’s quality of life, well-being, ability to work, and 

the family. (P) 

4 Recognize the importance of and demonstrate a commitment to the utilization of other 

healthcare professions in the treatment of anemia. (P, SBP) 


Sheth TN. Choudhry NK. Bowes M. Detsky AS. The relation of conjunctival pallor to the 

presence of anemia. J Gen Intern Med. 1997;12:102-6. 

Guyatt, G H. Oxman, A D. Ali, M. Willan, A. McIlroy, W. Patterson, C. Laboratory 

diagnosis of iron-deficiency anemia: an overview. J Gen Intern Med. 1992;7:145-53. 

Kis AM. Carnes M. Detecting iron deficiency in anemic patients with concomitant 

medical problems. J Gen Intern Med. 1998; 13:455-61. 

Bain BJ. Diagnosis from the blood smear. N Engl Journal Med. 2005;353:498-507. 

Weiss G. Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005;352:1011-23. 

78

Hoffbrand V. Provan D. ABC of clinical haematology: macrocytic anaemias. BMJ. 

1997;314:430-3. 

79

TRAINING PROBLEM #5: BACK PAIN 

RATIONALE: 

Back pain is one of the most commonly encountered problems in the outpatient, primary care internal 

medicine setting. It has an important differential diagnosis, and the initial decision-making must be 

made on the basis of clinical findings. As such, it is an excellent training condition for teaching 

decision-making based on careful collection and interpretation of basic clinical data. There is 

emerging data on test utility, especially as regards expensive spinal imaging, which facilitates 

teaching rational, cost-effective test ordering. Moreover, its requirement for skillful management, 

patient education, and support facilitate the teaching of these competencies. 





Anatomy and physiology of bony, soft tissue, vascular, and of the spine. 

Pathogenesis and pathophysiology of muscular strain, osteoarthritis, spinal stenosis, 

osteoporosis, disc degeneration, and spinal metastases. 

Pharmacology of non-narcotic and narcotic analgesics, nonsteroidal anti-inflammatory drugs, 

muscle “relaxants.” 



1. The symptoms, signs, and typical clinical course of the various causes of back pain including: 

Ligamentous/muscle strain (nonspecific musculoskeletal back pain). (MK) 

Degenerative arthritis (spondylosis). (MK) 

Disc herniation. (MK) 

Spinal stenosis. (MK) 

Vertebral compression fracture. (MK) 

Traumatic fracture. (MK) 

Sacroileitis. (MK) 

Spinal metastases. (MK) 

Spinal epidural abscess. (MK) 

Cauda equina syndrome. (MK) 

2. The role of diagnostic studies in the evaluation of the back pain there indications, 

limitations, cost: 

Plain radiography. (MK) 

CT. (MK) 

MRI. (MK) 

Myelogram. (MK) 

Electrodiagnosis (i.e. electromyography and nerve conduction studies). (MK) 

Bone densitometry. (MK) 

3. Response to therapy of the various etiologies, with understanding of the roles of: 

80

Bed rest. (MK) 

Exercise. (MK) 

Analgesia. (MK) 

NSAIDs. (MK) 

Heat/ice. (MK) 

Ultrasound. (MK) 

Spinal manipulation. (MK) 

Surgical interventions. (MK) 

4. Risk factor for and means of limiting disability and chronicity. (MK) 

5. Fear avoidance behaviors. (MK) 

6. Pain related behaviors with regard to chronic narcotic use. (MK) 

B. SKILLS: Students should be able to demonstrate specific skills including: 


age-appropriate medical history, that differentiates among etiologies of disease, 

including: 

Cancer history. (PC, CS) 

Weight loss. (PC, CS) 

Fever. (PC, CS) 

Recent infection. (PC, CS) 

Intravenous drug use. (PC, CS) 

Steroid use. (PC, CS) 

Trauma. (PC, CS) 

Rapidly progressive focal numbness and/or weakness. (PC, CS) 

Bowel/bladder dysfunction. (PC, CS) 

Saddle anesthesia. (PC, CS) 

Symptoms of systemic rheumatologic conditions. (PC, CS) 

Anatomic abnormalities (e.g. kyphosis, scoliosis). (PC, CS) 



Examination of the spine. (PC) 

Neurologic examination of the lower extremities. (PC) 

Straight leg raising test. (PC) 

Testing for saddle anesthesia. (PC) 

Assessment of rectal tone. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology for back 

pain (PC, MK) 




characteristics as well as patient preferences. 


ESR. (PC, MK) 

CBC. (PC, MK) 

Serum Alk Phos. (PC, MK) 

Students should be able to define the indications for and interpret (with consultation) the 

81

esults of: 

Plain spinal radiography. (PC, MK) 

Spinal CT. (PC, MK) 

Spinal MRI. (PC, MK) 

Radionuclide bone scan. (PC, MK) 

Bone densitometry. (PC, MK) 

Electrodiagnostic tests. (PC, MK) 



CS) 

Explain the importance of active participation in the treatment plan. (PC, CS) 

Elicit questions from the patient and their family about the management plan. 

(PC, CS) 



Patient education about the typical course of back pain. (PC, MK) 

Methods to prevent the development of chronic back pain. (PC, MK) 

Proper use of analgesics, NSAIDs, muscle relaxants, and local heat/ice. (PC, MK) 

Teaching back hygiene measures, exercises, and proper lifting and standing ergonomics. 

(PC, MK) 

Counseling patients about lifestyle modifications including weight loss. (PC, MK) 

The potential role of chiropractic, acupuncture, and massage (PC, MK) 

Determining when to obtain consultation from an appropriate back pain specialist. (PC, 

SBP) 



issues related to back pain. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for back pain. (PLI, P) 

2 Recognize the importance of patient preferences when selecting among diagnostic and 

therapeutic options for back pain. (P) 

3 Appreciate the importance of active patient involvement in the treatment of back pain. (P) 

4 respond appropriately to patients who are nonadherent to treatment for back pain. (CS, P) 

5 respond appropriately to patients with chronic back pain (P) 

6 Demonstrate ongoing commitment to self-directed learning regarding back pain. (PLI, P) 

7 Appreciate the impact back pain has on a patient’s quality of life, well-being, ability to work, 

and the family. (P) 


healthcare professionals in the treatment of back pain. (P, SBP) 


Carragee EJ. Persistent low back pain. N Engl J Med. 2005;352:1891-8. 

Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363-70. 

Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care 

82

setting. J Gen Intern Med. 2001;16:120-31. 

Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is often 

impossible. Arch Intern Med. 2002;162:1444-7; discussion 1447-8. 

83

TRAINING PROBLEM #6: CHEST PAIN 

RATIONALE: 

Chest pain is a common and important presenting symptom for a variety of disorders, some of which 

may be life-threatening emergencies. The ability to distinguish chest pain caused by an acute 

coronary syndrome (unstable angina or acute myocardial infarction) from other cardiac, 

gastrointestinal, pulmonary, musculoskeletal or psychogenic etiologies is an important training 

problem for third-year medical students. 




Ability to communicate appropriately with patients of diverse backgrounds, including the elderly 

patient. 

Knowledge of the anatomy of the heart, chest and abdomen. 

Understanding of the epidemiology of heart disease. 

Knowledge of the pathogenesis and pathophysiology of cardiovascular disease. 

Knowledge of the pharmacology of cardiovascular drugs. 

Ability to perform a cardiovascular risk assessment and understand issues related to primary 

and secondary prevention of cardiovascular disease. 

Ability to understand the impact of illness on individuals and their families. 


A. KNOWLEDGE: Students should be able to define, describe and discuss: 

1 Symptoms and signs of chest pain that may be due to an acute coronary syndrome such as 

unstable angina or acute myocardial infarction. (MK) 

2 Symptoms and signs of chest pain that are characteristic of angina pectoris. (MK) 

3 Symptoms and signs of chest pain due to other cardiac causes such as: 

Atypical or variant angina (coronary vasospasm, Prinzmetal angina). (MK) 

Cocaine-induced chest pain. (MK) 

Pericarditis. (MK) 

Aortic dissection. (MK) 

Valvular heart disease (aortic stenosis, mitral valve prolapse). (MK) 

Non-ischemic cardiomyopathy. (MK) 

Syndrome X. (MK) 

4. Symptoms and signs of chest pain due to gastrointestinal disorders such as: 

Esophageal disease (GERD, esophagitis, esophageal dysmotility). (MK) 

Biliary disease (cholecystitis, cholangitis). (MK) 

Peptic ulcer disease. (MK) 

Pancreatitis. (MK) 

5. Symptoms and signs of chest pain due to pulmonary disorders such as: 

Pneumonia. (MK) 

Spontaneous pneumothorax. (MK) 

Pleurisy. (MK) 

Pulmonary embolism. (MK) 

84

Pulmonary hypertension/cor pulmonale. (MK) 

6. Symptoms and signs of chest pain due to musculoskeletal causes such as: 

Costochondritis. (MK) 

Rib fracture. (MK) 

Myofascial pain syndromes. (MK) 

Muscular strain. (MK) 

Herpes zoster. (MK) 

7. Symptoms and signs of chest pain due to psychogenic causes such as: 

Panic disorders. (MK) 

Hyperventilation. (MK) 

Somatoform disorders. (MK) 

8. Factors that may be responsible for provoking or exacerbating symptoms of ischemic chest 

pain by: 

Increasing myocardial oxygen demand. 

o Tachycardia or tachyarrhythmia. (MK) 

o Hypertension. (MK) 

o Increased wall stress (aortic stenosis, cardiomyopathy). (MK) 

o Hyperthyroidism. (MK) 

Decreasing myocardial oxygen supply. 

o Anemia. (MK) 

o Hypoxemia. (MK) 

9. Risk factors for the development of coronary heart disease: 

Age and gender. (MK) 

Family history of sudden death or premature CAD. (MK) 

Personal history of peripheral vascular or cerebrovascular disease. (MK) 

Smoking. (MK) 

Lipid abnormalities (includes dietary history of saturated fat and cholesterol). (MK) 

Diabetes mellitus. (MK) 

Hypertension. (MK) 

Obesity. (MK) 

Sedentary lifestyle. (MK) 

Cocaine use. (MK) 

Estrogen use. (MK) 

Chronic inflammation. (MK) 

10. 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. (MK) 

11. Role of a critical pathway or practice guideline in delivering high quality, cost-effective care for 

patients presenting with symptoms of chest pain in the outpatient clinic, emergency room or 

hospital. (MK, PC, SBP) 



appropriately complete medical history that differentiates among the common etiologies of 

chest pain. 

85

The initial medical history should allow students to categorize the patients’ symptoms as 

angina pectoris, atypical angina or non-cardiac chest pain. (PC, CS) 

Specifically, the medical history of a patient with chest pain should contain information 

about those clinical characteristics that are typical of angina pectoris: 

o Substernal location. (PC, CS) 

o Precipitated by exertion. (PC, CS) 

o Relieved by rest or nitroglycerin. (PC, CS) 

o Onset, duration, severity, radiation, presence or absence of associated symptoms (such 

as dyspnea, diaphoresis or lightheadedness). (PC, CS) 

The history of a patient with chest pain should also contain information about: 

o Risk factors for coronary heart disease. (PC, CS) 

o Previous history of ischemic heart disease or valvular heart disease (rheumatic fever, 

cardiac murmurs). (PC, CS) 

o Previous history of peripheral vascular disease or cerebrovascular disease. (PC, CS) 

Students should be able to use the medical history to assess the 

functional status of patients who present with ischemic chest pain. (PC, CS) 

2. Physical exam skills: Students should be able to perform a focused physical exam that 

includes the following elements: 

Accurate measurement of arterial blood pressure and recognition of the typical blood 

pressure findings that occur in patients with aortic stenosis, aortic insufficiency, and pulsus 

paradoxus. (PC) 

Assessment of major arterial pulses for abnormalities, including bruits. (PC) 

Assessment of the neck veins for jugular venous distention and, when necessary, 

evaluation for abdominal jugular reflux. (PC) 

Assessment of the conjunctiva and optic fundus. (PC) 

Assessment of the extremities to ascertain skin condition, including color, temperature and 

the presence of edema, xanthomas, cyanosis and clubbing. (PC) 

Assessment of the lungs for crackles, rhonchi, rubs and decreased breath sounds. (PC) 

Inspection and palpation of the anterior chest to identify right and left sided heaves, lifts, 

and thrills. (PC) 

Auscultation of the heart to determine rhythm, intensity of heart sounds, splitting of S2 and 

the presence of rubs, gallops (S3, S4, summation) or extra heart sounds (e.g. clicks). (PC) 

Auscultation of the heart to detect the presence of heart murmurs. When a heart murmur is 

present, students should be able to: 

o Identify timing (systolic vs. diastolic, holosystolic vs. ejection). (PC) 

o Describe pitch, location and pattern of radiation. (PC) 

o Gauge significance (innocent vs. pathologic, sclerosis vs. stenosis). (PC) 

Assessment of the abdomen to determine the presence of epigastric or right 

upper quadrant tenderness, hepatomegaly, abnormal pulsations or bruits. (PC) 


and recognize specific history, physical exam, and laboratory findings that suggest a diagnosis 

of myocardial ischemia rather than a non-ischemic cause of chest pain (GI, pulmonary, 

musculoskeletal, psychogenic or undetermined). (PC, MK) 




characteristics as well as patient preferences. Test interpretation should take into account: 

Important differential diagnostic considerations including the “must not miss” diagnoses. 

(PC, MK) 

86


Performance characteristics of individual tests (sensitivity, specificity, 

positive and negative predictive value, likelihood ratios). (PC, MK) 


Cardiac biomarkers indicative of myocardial necrosis. (PC, MK) 

12-lead ECG. (PC, MK) 

Chest radiograph. (PC, MK) 

ABG. (PC, MK) 

Students should be able to define the indications for, and interpret (with consultation) the 

results of the following diagnostic tests and procedures: 

Echocardiogram (transthoracic and transesophageal). (PC, MK) 

Exercise stress test. (PC, MK) 

Stress thallium (myocardial perfusion scan). (PC, MK) 

Dobutamine stress echocardiography. (PC, MK) 

Coronary angiography. (PC, MK) 

Electron beam CT scan (for coronary calcification). (PC, MK) 

Ventilation/perfusion lung (V/Q) scan. (PC, MK) 

Pulmonary embolism protocol CT scan. (PC, MK) 

Pulmonary angiography. (PC, MK) 


Communicate the diagnosis, prognosis and treatment plan to patients and their families. 

(PC, CS) 

As appropriate for age and gender, educate patients about risk factors for cardiovascular 

disease. (PC, CS) 

Counsel patients or facilitate the provision of counseling related to: 

o 

Smoking cessation. (PC, CS) 

o 

Reduction of dietary saturated fats and cholesterol. (PC, CS) 

o 

Restriction of dietary sodium intake. (PC, CS) 

o 

Weight reduction. (PC, CS) 

o 

Increased physical activity. (PC, CS) 

6. Basic procedural skills: Students should be able to: 

• Perform a 12-lead ECG. (PC) 



Identification of the indications, contraindications, mechanisms of action, adverse reactions, 

significant interactions, and relative costs of the following medications: 

o Anti-platelet agents (aspirin, clopidogrel). (PC, MK) 

o Nitroglycerin and long-acting nitrates. (PC, MK) 

o Beta-blockers. (PC, MK) 

o Angiotensin-converting enzyme inhibitors. (PC, MK) 

o Calcium channel blockers. (PC, MK) 

o Antithrombotic therapy (heparin, warfarin). (PC, MK) 

o Glycoprotein IIb/IIIa inhibitors. (PC, MK) 

o Lipid-lowering agents. (PC, MK) 

Identification of the indications, contraindications, complications, long-term outcomes and 

relative costs associated with the following treatment modalities for ischemic heart disease: 

o Thrombolytic therapy. (PC, MK) 

o Percutaneous coronary intervention (with or without stenting). (PC, MK) 

o Coronary artery bypass graft surgery (CABG). (PC, MK) 

87

Determining when to consult a cardiologist or other subspecialist in the management of 

patients with chest pain. (PC, SBP) 

Description of how the diagnosis and treatment of chest pain in special populations may 

differ (e.g. very elderly, associated co-morbidities). (PC, MK) 


issues related to chest pain. (PC, PLI) 



1. Understand the emotional impact of a diagnosis of coronary artery disease and its potential 

effect on lifestyle (work performance, sexual functioning, etc). (PC, P) 

2. Respond appropriately to patient who are nonadherent to lifestyle modifications. 

(CS, P) 

3. Recognize the importance of early detection and modification of risk factors that may 

contribute to the development of atherosclerosis. (PC, P) 


considerations in the selection of diagnostic and therapeutic interventions for chest pain. (PLI, 

P) 

5. Demonstrate ongoing commitment to self-directed learning regarding chest pain. (PLI, P) 


professions in the treatment of chest pain. (P, SBP) 


ACC/AHA 2002 guideline update for the management of patients with chronic stable 

angina--summary article: a report of the American College of Cardiology/American 

Heart Association Task Force on practice guidelines (Committee on the Management 

of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2003;41:159-68. 

http://www.acc.org/clinical/guidelines/stable/stable_clean.pdf 

Panju AA, Hemmeigarn BR, Guyatt GH, Simel DL. Is this patient having a myocardial 

infarction? JAMA. 1998;280:1256-63. 

Klompas M. Does this patient have an acute thoracic aortic dissection? JAMA. 

2002;287:2262-72. 

TRAINING PROBLEM #7: COUGH 

RATIONALE: 

Cough is one of the most common symptoms with which a patient will present in the outpatient 

setting. There are several common etiologies for cough of which a third year medical student 

should be aware, as well as more clinically concerning etiologies. A proper understanding of the 

pathophysiology, diagnosis, and treatment of cough is an important learning objective. 




88


Knowledge of respiratory anatomy, physiology and pathophysiology. 



1. The criteria used to classify a cough (e.g. acute vs. chronic, productive vs. non-productive). 

(MK) 

2. Symptoms, signs, pathophysiology, differential diagnosis, and typical clinical course of the 

most common causes cough: 

Acute cough: 

o 

Viral tracheitis. (MK) 

o 

o 

Acute bronchitis. (MK) 


Chronic cough: 

o Gastroesophageal reflux. (MK) 

o Post-nasal drip. (MK) 

o Asthma/reactive airways disease. (MK) 

o Angiotensin converting enzyme inhibitors. (MK) 

o Post-infectious. (MK) 

o Infectious (pertussis, tuberculosis). (MK) 

o Chronic bronchitis. (MK) 

o Bronchiectasis. (MK) 

o Pleural effusion. (MK) 

o Lung cancer. (MK) 

o Congestive heart failure. (MK) 



medical history that differentiates among the etiologies of disease, including: 

Onset. (PC, CS) 

Duration. (PC, CS) 

Exacerbating/relieving factors. (PC, CS) 

Associated symptoms (fever, chills, weight loss). (PC, CS) 

Presence or absence of hemoptysis. (PC, CS) 

Tobacco history. (PC, CS) 

Relevant past medical history. (PC, CS) 



Accurately determining respiratory rate and level of respiratory distress. (PC) 

Recognizing the pharyngeal signs of post nasal drip. (PC) 

Identifying rales, rhonchi, and wheezes. (PC) 

Recognizing signs of pulmonary consolidation. (PC) 

3. Differential diagnosis: Students should be able to generate a prioritorized differential 

diagnosis recognizing history, physical exam, and laboratory findings that suggest a specific 

etiology of cough. (PC, MK) 

4. Laboratory interpretations: Students should be able to recommend when to order diagnostic 

89






Pleural fluid cell count and chemistries. (PC, MK) 

PFTs. (PC, MK) 

Sputum Gram stain and sputum acid-fast stain. (PC, MK) 

Sputum culture and sensitivities. (PC, MK) 



Barium swallow. (PC, MK) 

Upper endoscopy. (PC, MK) 

Sputum cytology. (PC, MK) 

Chest CT scan. (PC, MK) 


Counsel and educate patients about environmental contributors to their disease, 

pneumococcal and influenza immunizations, and smoking cessation. (PC, CS) 

Communicate the diagnosis, prognosis, and treatment plan, and subsequent follow-up to 

the patient and his or her family. (PC, CS) 

Elicit input and questions from the patient and his or her family about the management 

plan. (PC, CS) 



Describing the indications, contraindications, mechanisms of action, adverse reactions, 

significant interactions, and relative costs of the various treatments, interventions, or 

procedures commonly used to diagnose and treat patients who present with symptoms of 

cough. (PC, MK, SBP) 

Determining when to obtain consultation from a pulmonologist, allergist, otolaryngologist, or 

gastroenterologist. (PC, SBP) 



issues related to patients with chronic cough. (PC, PLI) 

Incorporating patient needs and preferences. (PC, P) 



considerations in the selection of diagnostic and therapeutic interventions for cough. (PLI, P) 

2. Respond appropriately to patients who are non-adherent to treatment for cough and smoking 

cessation. (CS, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding diagnosis and 

management of cough. (PLI, P) 

4. Appreciate the impact that an acute or chronic cough has on a patient’s quality of life, wellbeing, 



professions in the treatment of cough. (P, SBP) 


90

Currie GP, Gray RD, McKay J. Chronic cough. BMJ. 2003;326:261. 

Irwin RS, Madison JM. The persistently troublesome cough. Am J Respir Crit Care Med. 

2002;165:1469-74. 

Jones HC, Chang SI. Clinical Inquires. What is the best approach to the evaluation and 

treatment of chronic cough? J Fam Pract. 2001;50:748-9. 

Irwin RS, Madison MJ. Primary care: the diagnosis and treatment of cough. N Engl J Med. 

2000;343:1715-21. 

Irwin RS, Boulet LP, Cloutier MM, et al. Managing cough as a defense mechanism and as a 

symptom. Consensus panel report of the American College of Chest Physicians. Chest. 

1998;114:133S-181S. 

91

TRAINING PROBLEM #8: DYSPNEA 

RATIONALE: 

Shortness of breath or dyspnea is one of the most common patient complaints encountered in 

internal medicine. It has a very large number of etiologic possibilities— some benign but many 

potentially life-threatening. Because of the latter, a systematic approach to dyspnea is crucial. 





Anatomy, physiology, and pathophysiology of the pulmonary, cardiac, neurologic, and 

musculoskeletal systems. 

Physiology of acid-base homeostasis. 



1. Major organ systems/pathologic states causing dyspnea and their 

pathophysiology, including: 

Cardiac. (MK) 

Pulmonary. (MK) 

Anemia/hypovolemia. (MK) 

Acid-base disorders and other metabolic derangements (MK) 

Neuromuscular weakness. (MK) 

Central neurologic derangements. (MK) 

2. The symptoms, signs, and laboratory values associated with respiratory failure and ventilatory 

failure. (MK) 

3. The alveolar-arterial oxygen gradient and the pathophysiologic states that can alter it. (MK) 

4. The potential risks of relying too heavily on pulse oximetry as the sole indicator of arterial 

oxygen content. (MK) 

5. The common causes of acute dyspnea, their pathophysiology, symptoms, and signs, including: 

Pulmonary edema. (MK) 

Pulmonary embolism. (MK) 


Acute exacerbation of COPD. (MK) 

Asthma. (MK) 

Cardiac ischemia. (MK) 

Pneumothorax. (MK) 

Anxiety. (MK) 

6. The common causes of chronic dyspnea their pathophysiology, symptoms, and signs, 

including: 

Congestive heart failure. (MK) 

COPD. (MK) 

Pulmonary parenchymal disease. (MK) 

Pulmonary vascular disease. (MK) 

92

Anemia. (MK) 

Neuromuscular weakness. (MK) 

7. Basic treatment options for the common causes of acute and chronic dyspnea. (MK) 

8. The utility of supplemental oxygen therapy and the potential dangers of overly aggressive 

oxygen supplementation in some pathophysiologic states. (MK) 




including: 

Quantity, quality, severity, duration, ameliorating/exacerbating factors of the dyspnea. (PC, 

CS) 

Associated symptoms such as fevers, chills, sweats, orthopnea, paroxysmal nocturnal 

dyspnea, wheezing, edema, chest pain, cough, sputum production, hemoptysis, 

palpitations, nausea, anxiety, dizziness, orthostasis, weakness. (PC, CS) 

History of pulmonary, cardiac, neuromuscular/neurologic, renal, hepatic, and coagulopathic 

disorders. (PC, CS) 

Risk factors for deep vein thrombosis/pulmonary embolism. (PC, CS) 

Ingestion of drugs and toxic substances, administration of IV fluids. (PC, CS 

Smoking and environmental exposures. (PC, CS) 




Assessing the use of accessory muscles for breathing. (PC) 

Accurately measuring pulsus paradox. (PC) 

Identifying bronchial breath sounds, rales, rhonchi, wheezes, and subcutaneous 

emphysema. (PC) 

Identifying signs of pulmonary consolidation and hyperresonance. (PC) 

Identifying signs of pleural effusion. (PC) 

Identifying signs of elevated central venous pressure. (PC) 

Identifying signs of hypovolemia. (PC) 

Identifying S3 gallop, edema, and pallor. (PC) 

Identifying signs of deep vein thrombosis. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology of 

dyspnea (PC, MK) 






CBC. (PC, MK) 

Electrolytes, BUN/Cr, GLC. (PC, MK) 

Pulse oximitry. (PC, MK) 

ABG. (PC, MK) 



Pulmonary function tests. (PC, MK) 

93


results of: 

Ventilation perfusion scintigraphy. (PC, MK) 

Chest CT. (PC, MK) 

Venous Doppler studies. (PC, MK) 

Cardiac stress test. (PC, MK) 

Echocardiography. (PC, MK) 





Counsel and educate patients about environmental contributors to their disease. (PC, CS) 

Counsel patients nonjudgmentally about smoking cessation. (PC, CS) 



7. Management skills: Students should able to develop an appropriate evaluation and treatment 

plan for patients that includes: 

A rapid triage approach to the acutely dyspneic patient. (PC, MK) 

An appropriate assessment of the patient’s oxygenation status. (PC, MK) 

Appropriate oxygen supplementation as indicated. (PC, MK) 

Management plans for pulmonary edema/congestive heart failure, pneumonia, COPD, 

asthma, pulmonary embolism, cardiac ischemia, hypovolemia, anemia, and pneumothorax. 

(PC, MK) 

Determining when to obtain consultation from an appropriate specialist. (PC, SBP) 



issues related to dyspnea. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for dyspnea. (PLI, P) 

2. Recognize the importance of patient preferences when selecting among diagnostic and 

therapeutic options for dyspnea. (P) 

3. Demonstrate ongoing commitment to self-directed learning regarding dyspnea. (PLI, P) 

4. Appreciate the impact dyspnea has/have on a patient’s quality of life, wellbeing, ability to work, 


5. Recognize the importance of and demonstrate a commitment to the utilization 

of other healthcare professionals in the diagnosis and treatment of dyspnea. (P, SBP) 

6. Show understanding for the difficulties patients face with smoking cessation. (P) 


Ingram RH and Braunwald E. (2005). Dyspnea and pulmonary edema. In Kasper DL, 

Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles 

94

of Internal Medicine. 16 th ed. New York, NY: McGraw-Hill; 2005:201-5. 

Zoorob RJ. Campbell JS. Acute dyspnea in the office. Am Fam Physician. 

2003;68:1803-10. 

Fedullo PF. Tapson VF. Clinical practice. The evaluation of suspected pulmonary 

embolism. N Engl J Med. 2003;349:1247-56. 

Manning HL. Schwartzstein RM. Pathophysiology of dyspnea. N Engl J Med. 

1995;333:1547-53. 

95

TRAINING PROBLEM #9: DYSURIA 

RATIONALE: 

Dysuria is a very common presentation in the outpatient setting. Given the amount of health care 

dollars that are spent on antibiotic treatment of urinary tract infections as well as the emergence of 

resistance, it is important for third year medical students to have a working knowledge of how to 

approach the patient with this complaint, and how to differentiate patients with cystitis from other 

common causes of dysuria. 





Knowledge of genitourinary anatomy, physiology and pathophysiology. 



1. Presenting signs and symptoms of the common causes of dysuria, including: 

Cystitis. (MK) 

Urethritis, gonococcal and non-gonococcal (e.g. chlamydia, trichomonas, HSV). (MK) 

Pyelonephritis. (MK) 

Acute and chronic prostatitis. (MK) 

Epididymitis. (MK) 

Vaginitis (yeast, bacterial vaginosis, trichomonas, atrophic, irritant). (MK) 

Interstitial cystitis. (MK) 

2. Symptoms and signs of pyelonephritis and how to distinguish an upper from a lower UTI. (MK) 

3. Common bacteria that cause UTI. (MK) 

4. Aspects of pathogenesis that affect UTI, including gender, sexual activity, diabetes, anatomic 

anomalies, instrumentation, and use of an indwelling catheter. (MK) 

5. Indications for pursuing further work up for patients with UTI. (MK) 



history that differentiates among etiologies of dysuria, including: 

Timing, frequency, severity, and location of dysuria. (PC, CS) 

Fever, chills, sweats. (PC, CS) 

Frequency, urgency, hesitancy, incomplete voiding. (PC, CS) 

Back, abdominal, and groin pain. (PC, CS) 

History of nephrolithiasis. (PC, CS) 

Hematuria. (PC, CS) 

Vaginal or penile discharge. (PC, CS) 

Penile skin lesions. (PC, CS) 

Sexual activity. (PC, CS) 

History of sexual transmitted diseases. (PC, CS) 

96

Dyspareunia. (PC, CS) 

Scrotal, testicular, and perineal pain. (PC, CS) 

Use of topical hygiene products. (PC, CS) 



Percussion and palpation of the bladder to accurately recognize distention and tenderness. 

(PC) 

Palpation over the kidneys to elicit flank tenderness. (PC) 

Palpation of the abdomen to elicit tenderness. (PC) 

Palpation and massage of the male prostate to obtain discharge. (PC) 

Accurate recognition of perineal or vaginal atrophy and inflammation. (PC) 

Techniques of the pelvic examination to assess for causes of vaginitis. (PC) 

3. Differential diagnosis: Students should be able to generate a differential diagnosis 

recognizing specific history, physical exam, and laboratory findings that suggest a specific 

etiology of dysuria. (PC, MK) 






Urinalysis interpretation including cells and casts, urine dipstick and Gram stain when 

appropriate. (PC, MK) 

Urine culture. (PC, MK) 

Gram stain and culture of urethral or cervical discharge. (PC, MK) 

KOH stain and normal saline wet prep of vaginal discharge. (PC, MK) 

Urinary or cervical PCR to test for gonorrhea and Chlamydia. (PC, MK) 

KUB radiograph. (PC, MK) 






Counsel patients about safe sexual activity. (PC, CS) 

Explain the risk of recurrent UTI and counsel regarding preventative measures. (PC, CS) 



Selecting appropriate empiric antibiotic therapy for cystitis, pyelonephritis or urethritis prior 

to culture results. (PC, MK) 

Counseling patients on symptomatic therapies for acute cystitis. (PC, MK) 

Selecting the appropriate duration of therapy for cystitis and pyelonephritis. (PC, MK) 

Evaluating and managing patients with recurrent urinary tract infections including 

prophylaxis. (PC, MK) 

Choosing appropriate treatment for vaginitis depending on results of evaluation. (PC, MK) 

Understanding the treatment of prostatitis based on probable organisms and age. (PC, MK) 

Determining when to obtain consultation from a urologist or gynecologist. (PC, MK) 



issues related to dysuria. (PC, PLI) 

97




considerations in the selection of diagnostic and therapeutic interventions for dysuria. (PLI, P) 

2. Recognize the importance of patient needs and preferences when selecting among diagnostic 

and therapeutic options for dysuria. (P) 

3. Demonstrate ongoing commitment to self-directed learning regarding dysuria. (PLI, P) 

4. Recognize the importance of and demonstrate a commitment to the utilization of other 

healthcare professionals in the treatment of dysuria. (P, SBP) 


32. 

Bremnor JD, Sadovsky R. Evaluation of dysuria in adults. Am Fam Physician. 

2002;65:1589-96. 

Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute 

uncomplicated urinary tract infection? JAMA. 2002;287:2701-10. 

Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004;70:2125- 

Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection in 

women. N Engl J Med. 2003;349:259-66. 

98

TRAINING PROBLEM #10: FEVER 

RATIONALE: 

Because fever can have many infectious or noninfectious causes, patients with fever should be 

stratified by host susceptibility factors and evaluated in a systematic manner. A rational approach to 

patients with fever will help clinicians recognize presentations that need immediate attention, limit 

unnecessary diagnostic testing in less seriously ill patients, and help inform therapeutic decision 

making. 





Physiology and pathophysiology of thermoregulation and the immune response. 

Pharmacology of antipyretics. 



1. Physiology of the acute febrile response, including the: 

Beneficial and detrimental effects of fever upon the host. (MK) 

The differences in clinical manifestations between immunocompetent and 

immunocompromised patients. (MK) 

2. Risk factors and co-morbidities that are important in determining the host response to infection 

(e.g. neutropenia, asplenia, cirrhosis, alcoholism, diabetes, corticosteroid use, malnutrition, T 

cell dysfunction) (MK) 

3. Etiology of fever in special populations, including patients with a history of: 

Neutropenia due to cancer-related myelosuppression. (MK) 

HIV disease. (MK) 

Intravenous drug abuse. (MK) 

Recent international travel or immigration. (MK) 

Concomitant skin rash and lymphadenopathy. (MK) 

4. Pathophysiology and clinical presentation of patients with sepsis syndromes. (MK) 

5. Common causes of prolonged fever without apparent source, including: 

FUO in a normal host. (MK) 

Nosocomial FUO. (MK) 

Neutropenic FUO. (MK) 

FUO associated with HIV disease. (MK) 



medical history that differentiates among etiologies of disease, including: 

Chronology, duration and pattern of fever. (PC, CS) 

Associated symptoms. (PC, CS) 

Immune status and baseline co-morbidities. (PC, CS) 

Immunization status. (PC, CS) 

99

Relevant history of exposures. (PC, CS) 

Occupational, travel, family, and sexual history. (PC, CS) 

Medication history, including use of over-the-counter and illicit drugs. (PC, CS) 

3. Physical exam skills: Students should be able to perform a complete physical exam to 

determine the severity of disease and establish a preliminary hypothesis about the cause of 

fever. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology: 

Infection. (PC, MK) 

Rheumatologic disease/inflammatory disorder. (PC, MK) 

Malignancy. (PC, MK) 

Drug reaction. (PC, MK) 







UA with exam of urinary sediment. (PC, MK) 

Chest radiography. (PC, MK) 


Urine cultures. (PC, MK) 

Sputum Gram stain and cultures. (PC, MK) 

Sputum AFB stain and culture. (PC, MK) 

ESR and/or specific rheumatologic tests. (PC, MK) 

PPD. (PC, MK) 

Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell 

counts, staining, cultures, cytology, cryptococcal antigen, VDRL). (PC, MK) 

Chemistries, Gram stain, and culture of abnormal fluid collections 

(e.g. pleural effusion, ascites, abscesses). (PC, MK) 

Stool culture of enteric pathogens. (PC, MK) 

Stool Clostridium difficile toxin assay. (PC, MK) 

Stains and cultures from the throat, urethra, anus, cervix, vagina. (PC, MK) 

HIV ELISA and western blot. (PC, MK) 



CT imaging. (PC, MK) 


Tissue biopsy. (PC, MK) 


Communicate the diagnosis, treatment plan, and subsequent follow-up patients. (PC, CS) 

Elicit questions from the patient and their family about the management plan. (PC, CS) 


Obtain blood, wound, and throat cultures. (PC) 

Place and interpret a PPD. (PC) 



100

Developing an appropriate evaluation plan for patients with fever including ordering and 

interpreting appropriate laboratory and radiographic studies. (PC) 

Assessing the severity of presentation based on the history, host factors, physical exam 

and laboratory results and recognizing presentations that need immediate attention. (PC) 

Developing an appropriate treatment plan for patients with fever including the selection of 

an initial, empiric treatment regimen for neutropenic patients with fever and/or patients with 

life threatening sepsis. (PC) 

Determining when to obtain consultation from an appropriate specialist. (PC, SBP) 



issues related to fever. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for fever. (P, PLI) 

4. Appreciate the impact fever has on a patient’s quality of life, well-being, ability to work, and 

family; recognize the emotional impact of differential diagnosis. (P) 


healthcare professions in the diagnosis and treatment of fever. (P, SBP) 


Dinarello CA, Gelfand JA. (2005). Fever and hyperthermia. In Kasper DL, Braunwald 

EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal 

Medicine. 16 th ed. New York, NY: McGraw-Hill; 2005:104-8. 

Kaye ET, Kaye KM. (2005). Fever and rash. In Kasper DL, Braunwald EB, Fauci AS, 

Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16 th 

ed. New York, NY: McGraw-Hill; 2005:108-16. 

Gelfand JA, Callahan MV. (2005). Fever of unknown origin. In Kasper DL, Braunwald 



Roth AR, Basello GM. Approach to the adult patient with fever of unknown origin. Am 

Fam Physician. 2003;68:2223-8. 

101

TRAINING PROBLEM #11: FLUID, ELECTROLYTE AND 

ACID-BASE DISORDERS 

RATIONALE: 

Many disease processes can cause serious disturbances in the fluid, electrolyte and acid-base 

status of patients. Clinicians must be prepared to identify and correct these disturbances as 

efficiently as possible, thus making it an important training problem for third year medical students. 





Knowledge of pathogenesis and pathophysiology of fluid, electrolyte and acid-base disorders. 

Knowledge of medications that can cause alterations in fluid and electrolyte status as well as 

disturbance of acid-base status. 



1. The pathophysiology of: 

Hypo- and hypervolemia. (MK) 

Hypo- and hypernatremia. (MK) 

Hypo- and hyperkalemia. (MK) 

Hypo- and hypercalcemia. (MK) 

Simple and mixed acid-base disorders. (MK) 

Hypo- and hyperphosphatemia. (MK) 

Hypo- and hypermagnesemia. (MK) 

Respiratory acidosis and alkalosis. (MK) 

Metabolic acidosis and alkalosis. (MK) 

2. Presenting symptoms and signs of the above disorders. (MK) 

3. The importance of total body water and its distribution. (MK) 

4. The differential diagnosis of hypo- and hypernatremia in the setting of volume depletion, 

euvolemia, and hypervolemia. (MK) 

5. How to distinguish hyponatremia from pseudohyponatremia. (MK) 

6. How to identify spurious hyperkalemia or acidosis-related hyperkalemia. (MK) 

7. Risks of too rapid or delayed therapy for hyponatremia. (MK) 

8. The most common causes of respiratory acidosis, respiratory alkalosis, metabolic acidosis and 

metabolic alkalosis. (MK) 

9. How to calculate the anion gap and explain its relevance to determining the cause of a 

metabolic acidosis. (MK) 

10. Changes in total body water distribution that occur with aging. (MK) 

11. How altered mental status can contribute to electrolyte disorders. (MK) 

12. Tests to use in the evaluation of fluid, electrolyte, and acid-base disorders. (MK) 

13. Indications for obtaining an ABG. (MK) 

102

14. The types of fluid preparations to use in the treatment of fluid and electrolyte disorders. (MK) 

B. SKILLS: Students should demonstrate specific skills, including: 



Eliciting appropriate information from patients with volume overload, including recent weight 

gain, edema or ascites, symptoms of heart failure, dietary sodium intake, changes in 

medications, noncompliance and intravenous fluid regimens. (PC, CS) 

Eliciting appropriate information from patients with volume depletion, including recent 

weight loss, thirst, gastrointestinal losses, urinary losses, oral intake, insensible losses, and 

intravenous fluid regimens. (PC, CS) 

Eliciting appropriate information from patients with electrolyte problems, including use of 

diuretics and other medications, gastrointestinal losses, and history of relevant medical 

conditions (e.g., heart failure, liver disease, renal disease, pulmonary disease, central 

nervous system disease, and malignancy). (PC, CS) 



Measurement of orthostatic vital signs. (PC) 

Identification of signs of volume overload including peripheral edema, pulmonary edema, 

ascites, edema. (PC) 

Identification of signs of volume depletion including tachycardia, orthostatic hypotension, 

dry mucous membranes, poor skin turgor. (PC) 

Identification of signs of sodium disorders including lethargy, weakness, encephalopathy, 

delirium, seizures. (PC) 

Identification of signs of potassium disorders including weakness, fatigue, constipation, 

ileus, cramping, tetany, hypo- or hyperreflexia. (PC) 

Identification of signs of calcium disorders including cramping, tetany, Chvostek’s and 

Trousseau’s sign, seizures, anorexia, constipation, polyuria, hypo- or hyperreflexia, stupor, 

coma. (PC) 


diagnosis recognizing specific history, physical exam, and laboratory findings that 

distinguish between: 

Hypo- and hypervolemia. (PC, MK) 

Hypo- and hypernatremia. (PC, MK) 

Hypo- and hyperkalemia. (PC, MK) 

Hypo- and hypercalcemia. (PC, MK) 

Hypo- and hyperphosphatemia. (PC, MK) 

Hypo- and hypermagnesemia. (PC, MK) 

Respiratory acidosis and alkalosis. (PC, MK) 

Metabolic acidosis and alkalosis. (PC, MK) 






Serum electrolytes, BUN/Cr. (PC, MK) 

Anion gap. (PC, MK) 

103

ABG. (PC, MK) 

Serum and urine osmolality. (PC, MK) 

Urinary sodium. (PC, MK) 

Fractional excretion of sodium. (PC, MK) 

ECG findings in hyper- and hypokalemia. (PC, MK) 


Explain to a patient and his or her family why intravenous fluids are needed. (PC, CS) 



Elicit input and questions from the patient and their family about the management plan. 

(PC, CS) 


Insert a peripheral intravenous catheter. (PC) 


Assist in the insertion of a central venous catheter. (PC) 



Writing appropriate fluid orders for the treatment of hypo- and hypervolemia, hypo- and 

hypernatremia, hypo- and hyperkalemia, hypo- and hypercalcemia. (PC, MK) 

Writing appropriate orders for replacing sodium, potassium, calcium, phosphates, and 

magnesium. (PC, MK) 

Writing appropriate orders for correcting hyperkalemia, hypercalcemia, hyperphosphatemia 

and hypermagnesemia. (PC, MK) 

Calculating the water deficit that needs to be corrected to treat hypernatremia. (PC, MK) 

Identifying indications for administration of bicarbonate. (PC, MK) 

Determining when to obtain consultation from a nephrologist. (PC, SBP) 



issues related to fluid, electrolyte, and acid-base disorders. (PC SBP) 




considerations in the selection of diagnostic and therapeutic interventions for problems related 

to fluid, electrolyte and acid-base disorders. (PLI, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding fluid, electrolyte and 

acid-based disorders. (PLI, P) 


professions in the treatment of problems related to fluid, electrolyte and acid-base disorders. 

(P, SBP) 


Singer GG, Brenner BM. Fluid and Electrolyte Disturbances. In Kasper DL, Braunwald 



DuBose TD. (2005). Acidosis and Alkalosis. In Kasper DL, Braunwald EB, Fauci AS, 

104

Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16 th 


Preston RA. Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple. Miami, FL: 

MedMaster Incorporated; 2002. 

Adrogue HJ. Madias NE. Hyponatremia. N Engl J Med. 2000;342:1581-9. 

Adrogue HJ. Madias NE. Hypernatremia. N Engl J Med. 2000;342:1493-9. 

Stewart AF. Clinical practice: Hypercalcemia associated with cancer. N Engl J Med. 

2005;352:373-9. 

Carroll MF. Schade DS. A practical approach to hypercalcemia. Am Fam Physician. 

2003;67:1959-66. 

Gennari FJ. Hypokalemia. N Engl J Med. 1998;339:451-8. 

105

TRAINING PROBLEM #12: GASTROINTESTINAL BLEEDING 

RATIONALE: 

Gastrointestinal bleeding is a common disorder which can be life-threatening if not properly 

diagnosed and treated. Knowledge of etiology, risk factors, approach, and management is 

integral to internal medicine training. 

Prerequisites: 




Anatomy, physiology, and pathophysiology of the gastrointestinal tract. 

Pharmacology of non-steroidal anti-inflammatory medication (a major contributing factor in 

etiology of gastrointestinal bleeding) as well as proton pump inhibitors and other agents used 

in the acute setting for treatment of gastrointestinal bleeding. 



1. The common causes for and symptoms of upper and lower gastrointestinal blood loss, 

including: 

Esophagitis/esophageal erosions. (MK) 

Mallory Weiss tear. (MK) 

Peptic and duodenal ulcer disease. (MK) 

Esophageal/gastric varices. (MK) 

Erosive gastritis. (MK) 

Arteriovenous malformations. (MK) 

Gastrointestinal tumors, benign and malignant. (MK) 

Diverticulosis. (MK) 

Ischemic colitis. (MK) 

Hemorrhoids. (MK) 

Anal fissures. (MK) 

2. The distinguishing features of upper versus lower GI bleeding (MK) 

3. The indications for inpatient versus outpatient evaluation and treatment (MK) 

4. The principles of stabilization and treatment of acute massive GI blood loss. (MK) 

5. The role of contributing factors in GI bleeding such as H. pylori infection; NSAIDs, alcohol, 

cigarette use, coagulopathies; and chronic liver disease. (MK) 


1. History-taking skills: Students should be able to obtain, document, and present an age 

appropriate history that differentiates among etiologies of disease, including: 

Features that distinguish upper from lower GI bleeding. (PC, CS) 

Quantification of degree of blood loss. (PC, CS) 

Chronology and duration of bleeding. (PC, CS) 

Associated symptoms. (PC, CS) 

106

Relevant past medical history. (PC, CS) 

Medication history, including use of tobacco and alcohol. (PC, CS) 

2. Physical exam skills: Students should be able to perform a physical examination to 

establish the diagnosis and severity of disease, including: 

Postural blood pressure and pulse. (PC, MK) 

Abdominal palpation for organomegaly, masses, and tenderness. (PC, MK) 

Search for stigmata of chronic liver disease. (PC, CS) 

Anal and rectal examination. (PC, CS) 


recognizing specific history and physical examination findings that suggest a specific etiology 

for GI bleeding. (PC, MK) 

4. Laboratory interpretation: Students should be able to recommend when to order 

diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating 

treatment based on the differential diagnosis, including consideration of test cost and 

performance characteristics as well as patient preferences. 


Stool and gastric fluid tests for occult blood. (MK, PC) 

CBC. (MK, PC) 

PT/PTT. (MK, PC) 

Hepatic function panel. (MK, PC) 

Tests for Helicobacter pylori. (MK, PC) 



Esophagogastroduodenoscopy (EGD). (MK, PC) 

Colonoscopy. (MK, PC) 

Barium studies of the gastrointestinal tract. (MK, PC) 



CS) 



Start an IV line using a large bore (i.e. 18 gauge) needle. (MK, PC) 

Perform a stool or emesis occult blood testing. (MK, PC) 



Establishing adequate venous access. (PC, MK) 

Administering crystalloid fluid resuscitation. (PC, MK) 

Ordering blood and blood product transfusion. (PC, MK) 

Determining when to obtain consultation from a gastroenterologist or a general surgeon. 

(PC, MK) 



issues related to gastrointestinal bleeding. (PC, PLI) 

Incorporating patient preferences. (PC,P) 

Outlining long-term management when appropriate (e.g. Helicobacter pylori eradication, 

antacid, H-2 blocker or proton pump inhibitor therapy, smoking /alcohol cessation, NSAID 

107

estriction, and dietary modification. (MK, CS) 



considerations in the selection of diagnostic and therapeutic interventions for gastrointestinal 

bleeding. (PLI, P) 

2. Respond appropriately to patients who are nonadherent to treatment for gastrointestinal 

bleeding. (CS, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding gastrointestinal bleeding. 

(PLI, P) 

4. Appreciate the impact gastrointestinal bleeding has on a patient’s quality of life, well-being, 


5. Recognize the importance and demonstrate a commitment to the utilization of 

6. other health care professions in the treatment of gastrointestinal bleeding. (P, SBP) 

D. RESOURCES: 

Fallah, MA, Prakash, C, Edmundowicz, S. Acute gastrointestinal bleeding. Med Clin 

North Am. 2000;84:1183-208. 

Laine L. (2005). Gastrointestinal bleeding. In Kasper DL, Braunwald EB, Fauci AS, 

Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16 th ed. 

New York, NY: McGraw-Hill; 2005:235-8. 

Del Valle J. (2005). Peptic ulcer disease and related disorders. In Kasper DL, 

Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of 

Internal Medicine. 16 th ed. New York, NY: McGraw-Hill; 2005:1746-62. 

Gearhart SL, Bulkley G. (2005). Common diseases of the colon and anorectum and 

mesenteric vascular insufficiency. In Kasper DL, Braunwald EB, Fauci AS, Hauser SL, Longo 

DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16 th ed. New York, NY: 

McGraw-Hill; 2005:1795-803. 

Mitchell SH, Schaefer DC. A new view of occult and obscure gastrointestinal 

bleeding. Am Fam Physician. 2004;69:875-81. 

108

TRAINING PROBLEM #13: KNEE PAIN 

RATIONALE: 

Musculoskeletal complaints are some of the most common problems for which patients seek medical 

attention, and the knee is the single most common joint pain. Many of these problems can be 

effectively tackled in the primary care setting without need for consultation. The principles presented 

in this training problem can be readily applied to other joint pains. 





Anatomy and physiology of the musculoskeletal system. 

Pharmacology of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), topical 

medications (capsaicin and lidocaine) and glucocorticoids. 

Basic bone radiograph interpretation. 



11. A systematic approach to joint pain based on an understanding of pathophysiology to classify 

potential causes. (MK) 

12. The effect of the time course of symptoms on the potential causes of joint pain (acute vs. 

subacute vs. chronic). (MK) 

13. The difference between and pathophysiology of arthralgia vs. arthritis and mechanical vs. 

inflammatory joint pain. (MK) 

14. The distinguishing features of intra-articular and periarticular complaints (joint pain vs. bursitis 

and tendonitis). (MK) 

15. 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). (MK) 

16. Indications for performing an arthrocentesis and the results of synovial fluid analysis. (MK) 

17. The utility of describing the relative location of knee pain (anterior, medial, lateral, posterior). 

(MK) 

18. The relative frequency of the various causes of knee pain. (MK) 

19. The differential diagnosis, pathophysiology, and typical presentations of the common intraarticular 

causes of knee pain: 

Osteoarthritis. (MK) 

Inflammatory arthropathies. (MK) 

Crystalline arthropathies. (MK) 

Septic arthritis. (MK) 

Patellofemoral pain syndrome. (MK) 

Cruciate ligament tear. (MK) 

Meniscal damage. (MK) 

10. The differential diagnosis, pathophysiology, and typical presentations of the common 

periarticular causes of knee pain: 

109

Collateral ligament sprain/tear. (MK) 

Ileotibial band syndrome. (MK) 

Prepatellar bursitis. (MK) 

Popliteal (Baker) cyst. (MK) 

11. Basic symptomatic treatment for knee pain, including: 

Relative rest. (MK) 

Ice/heat. (MK) 

Compression. (MK) 

Elevation. (MK) 

Acetaminophen. (MK) 

Nonsteroidal anti-inflammatory drugs. (MK) 

Glucosamine and chondroitin sulfate. (MK) 

Physical therapy. (MK) 

Assistive devices. (MK) 

Topical “analgesics.” (MK) 

Corticosteroid injection. (MK) 

12. Indications for and efficacy of intra-articular corticosteroid injections. (MK) 




Delineation of the specific features of the pain. (PC, CS) 

Presence of stiffness, swelling, warmth, redness. (PC, CS) 

Symptoms of instability, locking, clicking/popping, and weakness. (PC, CS) 

History of trauma, new activities, repetitive motion. (PC, CS) 

Impact on the patient’s ability to carry out activities of daily living. (PC, CS) 



Examination of the knee, including: 

o Inspection. (PC) 

o Palpation. (PC) 

o Range of motion. (PC) 

o Gait assessment. (PC) 

o Evaluation for effusion. (PC) 

o Assessment of ligamentous and cartilaginous stability. (PC) 

3 Differential diagnosis: Students should be able to generate a prioritized differential diagnosis 


knee pain. (PC, MK) 






Synovial fluid analysis. (PC, MK) 



Plain radiographs of the knee. (PC, MK) 

CT and MRI of the knee. (PC, MK) 

110



CS) 


6. Basic and advanced procedure skills: Students should be able to: 

Assist in the performance of an arthrocentesis and intra-articular corticosteroid injection. 

(PC) 



Determining when to perform an arthrocentesis. (PC, MK) 

Prescribing simple, nonmedicinal symptomatic measures such as rest, ice/heat, 

compression, and elevation. (PC, MK) 

Prescribing physical therapy and assistive devices (PC, MK) 

Prescribing exercise. (PC, MK) 

Counseling patients regarding weight loss. (PC, MK) 

Prescribing non-narcotic analgesics and anti-inflammatory agents. (PC, MK) 

Determining when to prescribe narcotic analgesics. (PC, MK) 

Determining when to prescribe intra-articular corticosteroid injection. (PC, MK) 

Determining when to obtain consultation from an orthopedic surgeon and rheumatologist. 

(PC, MK) 



issues related to knee pain. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for knee pain. (PLI, P) 


and therapeutic options for knee pain. (P) 

3. Respond appropriately to patients who are nonadherent to treatment for knee pain. 

(CS, P) 

4. Appreciate the impact chronic knee pain has on a patient’s quality of life, 

psychological well-being, ability to work, and the family. (P) 


other health care professions in the treatment of knee pain. (P, SBP) 

6. Appreciate the difficulty patients with limited mobility have in achieving weight loss. 

(P) 

7. Demonstrate an appropriate attitude in managing patients with chronic pain. (P) 


Cush JJ, Lipsky PE. (2005). Approach to articular and musculoskeletal disorders. In 

Kasper DL, Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. 

111

Harrison’s Principles of Internal Medicine. 16 th ed. New York, NY: McGraw-Hill; 

2005:2029-36. 

Brandt KD. (2005). Osteoarthritis. In Kasper DL, Braunwald EB, Fauci AS, Hauser SL, 

Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16 th ed. New 

York, NY: McGraw-Hill; 2005:2036-45. 

Principles of diagnosis and management: Pattern recognition in arthritis. In Klippel JH, 

Dieppe PA, Ferri FF, eds. Primary Care Rheumatology. St. Louis, MO: Mosby; 1999:11- 

7. 

Regional pain and monoarticular disorders: Pain in the knee. (1999). In Klippel JH, 

Dieppe PA, Ferri FF, eds. Primary Care Rheumatology. St. Louis, MO: Mosby; 1999:99- 

107. 

DeHaven KE. Knee and lower leg. In Greene WB, ed. Essentials of Musculoskeletal 

Care. 2 nd ed. Rosemont, IL: American Academy of Orthopedic Surgeons; 2001:341-405. 

112

TRAINING PROBLEM #14: RASH 

RATIONALE: 

Rash is an extremely common complaint. It may be the manifestation of a primary cutaneous 

disorder or secondary to a systemic condition. Internists see many patients with both and, 

therefore, must be acquainted with the diagnosis and management. 





Anatomy, physiology, and pathophysiology of the skin. 

Pharmacology of glucocorticoids, antifungals, antibiotics, benzoyl peroxide, salicylic acid, and 

retinoids and derivatives. 



3. The standard nomenclature used to describe rashes (macule, patch, papule, nodule, plaque, 

vesicle, pustule, bulla, cyst, wheal, telangiectasia, petechia, purpura, erosion, ulcer). (MK) 

4. The morphologic features used to describe potentially malignant skin lesions (Asymmetry, 

Border, Color, Diameter, Dynamic i.e. changing, Elevation, and Enlargement, “ABCDE”). (MK) 

5. The significance of focal, organ-based, and constitutional signs and symptoms in the context of 

a rash (e.g. rash and fever, rash and arthritis, rash and renal failure). (MK) 

4. The differential diagnosis, pathophysiology, and typical presentations of the common causes of 

eczematous dermatoses: 

Atopic dermatitis. (MK) 

Contact dermatitis. (MK) 

Stasis dermatitis. (MK) 

Seborrheic dermatitis. (MK) 


maculopapular eruptions: 

viral exanthems. (MK) 

bacterial exanthems. (MK) 

erythema multiforme. (MK) 


papulosquamous dermatoses: 

Psoriasis. (MK) 

Pityriasis rosea. (MK) 


cutaneous infections: 

Impetigo. (MK) 

Cellulitis. (MK) 

Folliculitis. (MK) 

Dermatophytosis (tinea corporis, tinea capitis, tinea cruris, tinea pedis, onychomycosis). 

(MK) 

113

Tinea versicolor. (MK) 

Candidiasis. (MK) 

Condylomata. (MK) 


8. The prevention of community acquisition of Methicillin-resistant Staphylococcus aureus 

(MRSA), including good hygiene practices: 

Keeping hands clean by washing thoroughly with soap and water or using an alcohol-based 

sanitizer. (MK) 

Keeping cuts and scrapes clean and covered with a bandage until healed. (MK) 

Avoiding contact with other people’s wounds or bandages. (MK) 

Avoiding sharing personal items such as towels and razors. (MK) 


pustular diseases: 

Acne. (MK) 

Rosacea. (MK) 


cutaneous ulcers. 

Venous insufficiency. (MK) 

Peripheral arterial disease. (MK) 

Neuropathic. (MK) 

11. The significance of palpable purpura and other cutaneous findings of vasculitis. (MK) 


urticaria and angioedema. (MK) 

13. The differential diagnosis, pathophysiology, and typical presentations of drug eruptions. (MK) 


benign neoplasms and hyperplasias: 

Seborrheic keratosis. (MK) 

Epidermoid cyst. (MK) 


premalignant lesions and malignancies: 

Actinic keratosis. (MK) 

Basal cell carcinoma. (MK) 

Squamous cell carcinoma. (MK) 

Malignant melanoma. (MK) 

16. The differential diagnosis, pathophysiology, and typical presentations of the cutaneous 

manifestations of sexually transmitted diseases. 

Syphilis. (MK) 

Disseminated gonorrhea infection. (MK) 

Human papilloma virus. (MK) 

Herpes simplex virus. (MK) 

17. The differential diagnosis, pathophysiology, and typical presentations of the cutaneous 

manifestations of internal/systemic diseases. (MK) 

18. The general indications for skin biopsy. (MK) 




Evolution (site of onset, manner of spread, duration). (PC, CS) 

114

Symptoms associated with the rash (pruritis, pain, photosensitivity, malaise, fever, 

arthralgias). (PC, CS) 

Past medical history of systemic diseases known to have cutaneous manifestation. (PC, 

CS) 

Sexual history. (PC, CS) 

Medication usage and allergies. (PC, CS) 

Skin care product usage. (PC, CS) 

Chemical skin exposure. (PC, CS) 

Sun exposure. (PC, CS) 

Travel history. (PC, CS) 


diagnosis and severity of disease including: 

Description of the type of primary skin lesion (macule, patch, papule, nodule, plaque, 

vesicle, pustule, bulla, cyst, wheal, telangiectasia, petechia, purpura, erosion, ulcer). (PC) 

Description of the shape, margination, color, arrangement, and distribution of the individual 

lesions. (PC) 

Describe potentially malignant lesions in terms of Asymmetry, Border, Color, Diameter, 

Elevation, and Enlargement (“ABCDE”). (PC) 

Presence of exudates: dry (crust) or wet (weeping) exudates. (PC) 

Presence of scale or lichenification. (PC) 

Palpation of lesions for consistency, alteration of temperature, mobility, and tenderness. 

(PC) 


diagnosis recognizing specific history and physical exam findings that suggest a specific 

etiology for a rash. (PC, MK) 


diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating 

treatment based on the differential diagnosis, including consideration of test cost and 

performance characteristics as well as patient preferences. 


KOH preparation. (PC, MK) 


RPR and VDRL. (PC, MK) 

Bacterial culture. (PC, MK) 


significance of the results of: 

• Skin biopsy. (PC, MK) 


Explain the dangers of excess sun exposure. (PC, CS) 




Counsel patients regarding the prevention of community acquisition of MRSA. (PC, CS) 


Perform a skin scraping and KOH preparation. (PC) 



Determining when to perform a skin scraping and KOH preparation. (MK, PC) 

Determining when to obtain tests appropriate for the diagnosis of systemic medical 

115

conditions suspected as the cause of rash. (MK, PC) 

Prescribing a simple hypoallergenic skin care regimen. (MK, PC) 

Prescribing appropriate moisturizing/emollient treatment. (MK, PC) 

Discussing the importance of and prescribing sunscreen use. (PC, MK, CS) 

Prescribing appropriate treatment for eczematous dermatoses, mild psoriasis, common 

cutaneous skin infections, acne, rosacea, venous stasis dermatitis and ulcers, and common 

drug eruptions. (PC, MK) 

Determining when to obtain a consultation from a dermatologist. (PC) 



issues related to common dermatologic complaints. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for rashes. (PLI, P) 


therapeutic options for rashes. (P) 

5. Appreciate the impact rashes have on a patient’s quality of life, well-being, ability to work, 



Drage LA. Life-threatening rashes: dermatologic signs of four infectious diseases. Mayo 

Clin Proc. 199;74:68-72. 

Williams HC. Clinical practice. Atopic dermatitis. N Engl J Med. 2005;352:2314-24. 

Abbasi NR. Shaw HM. Rigel DS. Friedman RJ. McCarthy WH. Osman I. Kopf AW. 

Polsky D. Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria. JAMA. 

2004;292:2771-6. 

James WD. Clinical practice. Acne. N Engl J Med. 2005;352:1463-72. 

Wolff K, Johnson AJ, Suurmond R. Fitzpatrick’s Color Atlas & Synopsis of Clinical 

Dermatology. 4 th ed. New York, NY; 2005. 

American Academy of Dermatology 

Medical Student Core Curriculum 

www.aad.org/professionals/Residents/MedStudCoreCurr/MedStudCoreC urr.htm 

Community-Associated MRSA 

Division of Healthcare Quality Promotion 

National Center for Infectious Diseases 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html 

116

TRAINING PROBLEM #15: UPPER RESPIRATORY COMPLAINTS 

RATIONALE: 

Upper respiratory tract infections (URIs) are some of the most common problems for which patients 

seek medical attention. Many patients inappropriately receive antibiotic therapy for these mostly 

viral infections. 





Anatomy and physiology of the upper airway, Eustachian tubes, and sinuses. 

Anatomy and physiology of the respiratory system. 

Pathogenesis and pathophysiology of upper respiratory tract diseases. 

Microbial pathogens associated with upper respiratory tract infections. 

Pharmacology of antibiotics. 



1. A rational approach to the common URIs: nasal congestion, rhinorrhea, facial pain/tenderness, 

cough, sputum production, sore throat, and ear pain. (MK) 

2. Common constitutional symptoms that accompany URIs: generalized weakness, fatigue, 

malaise, headache, mild myalgias, and modest fever. (MK) 

3. The microbiology of URIs, highlighting the relative frequencies of viral and bacterial etiologies. 

(MK) 

4. The most common microbiologic agents that cause the common URIs. (MK) 

5. The pathophysiology and typical clinical presentation of the common URIs: 

Common cold. (MK) 

Acute bronchitis. (MK) 

Pharyngitis. (MK) 

Acute sinusitis. (MK) 

Otitis media. (MK) 

6. The pathophysiologic similarities between the common cold and acute sinusitis. (MK) 

7. The clinical features and microbiology of acute compared to chronic sinusitis. (MK) 

8. The pathophysiology and symptomatology of allergic rhinitis and the clinical features that may 

help differentiate it from the common cold and acute sinusitis. (MK) 

9. The clinical features that may help differentiate the common URIs from influenza. (MK) 

10. The pathophysiology and clinical features of acute compared to chronic bronchitis. (MK) 

11. The pathophysiology and clinical features of acute bronchitis compared to pneumonia. (MK) 

12. The pathophysiology and clinical features of otitis media and Eustachian tube malfunction. 

(MK) 

13. The signs and symptoms that may help distinguish viral from bacterial pharyngitis. (MK) 

14. Symptomatic treatment for URIs and the major side effects/contraindications for these 

treatments, including: 

Decongestants. (MK) 

Non-selective antihistamines. (MK) 

117

Mucolytics. (MK) 

Cough suppressants. (MK) 

Pain relievers/fever reducers. (MK) 

15. The general role of antibiotics in the treatment of URIs and specific evidence-based indications 

for them. (MK) 

16. The basic elements of the treatment of allergic rhinitis. (MK) 

17. The use of antiviral agents in the prophylaxis and treatment of influenza. (MK) 



medical history, that differentiates among etiologies of disease, including: 

The predominant symptom (nasal congestion/rhinorrhea, purulent nasal discharge with 

facial pain/tenderness, sore throat, cough with or without sputum, sore throat or ear pain). 

(PC, CS) 

Constitutional symptoms. (PC, CS) 

Symptoms of potential pneumonia. (PC, CS) 

History of or symptoms of serious cardiopulmonary diseases (e.g. asthma, chronic 

obstructive pulmonary disease, congestive heart failure) that may alter the treatment plan. 

(PC, CS) 



Examination of the nasal cavity, pharynx, and sinuses. (PC) 

Otoscopic examination. (PC) 

Evaluation of the head and neck for lymphadenopathy. (PC) 

Auscultation of the lungs to distinguish pulmonary consolidation, pleural effusion, 

pulmonary congestion, and chronic obstructive pulmonary disease. (PC) 



upper respiratory complaints: 

Common cold. (PC, MK) 

Acute sinusitis. (PC, MK) 

Chronic sinusitis. (PC, MK) 

Allergic rhinitis. (PC, MK) 

Pharyngitis. (PC, MK) 

Otitis media. (PC, MK) 

Otitis externa. (PC, MK) 

Acute bronchitis. (PC, MK) 

Chronic bronchitis. (PC, MK) 

Influenza. (PC, MK) 

Pneumonia. (PC, MK) 

Infectious mononucleosis. (PC, MK) 




characteristics as well as patient preferences Laboratory and diagnostic tests should include, 


CBC with differential. (PC) 

Rapid strep test. (PC) 

118

Throat culture. (PC) 

Chest radiograph. (PC) 

PFTs. (PC) 

Monospot/heterophile antibody. (PC) 



his or her family. (CS) 

Elicit questions from the patient and his or her family about the management plan. (CS) 

Explain the microbiologic origin of most URIs and why antibiotics are generally ineffective. 

(CS) 

Explain the importance of antimicrobial resistance. (CS) 

6. Basic and advanced procedure skills: 

• Throat culture. (PC) 



Determining when to obtain a chest radiograph. (PC, MK) 

Determining when to prescribe antibiotics. (PC, MK) 

Selecting the most appropriate antibiotic for acute bacterial sinusitis, streptococcal 

pharyngitis, and bacterial otitis media. (PC, MK) 

Prescribing symptomatic treatments. (PC, MK) 

Determining when to obtain consultation from an allergist, otolaryngologist, or 

pulmonologist. (PC, SBP) 



issues related to URIs. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for common URI complaints. 

(P, PLI) 

2 Appreciate the impact common URI complaints have on a patient’s quality of life, well-being, 


3 Discuss the patient’s perspective regarding the use of antibiotics for URIs. (CS, P) 

4 Discuss the role physicians play in the over-prescribing of antibiotics for URIs. (P) 

5 Discuss the importance of antimicrobial resistance from the point of view of the individual and 

society at large. (P) 


Arroll B, Kenealy T. Antibiotics for the common cold and acute purulent rhinitis. 

Cochrane Database Syst Rev. 2005;(3):CD000247. 

Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344:205-11. 

Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database 

Syst Rev. 2004;(2):CD000023. 

Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired 

pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 

1997;278:1440-5. 

119

Smucny J, Fahey T, Becker L, et al. Antibiotics for acute bronchitis. Cochrane 

Database Syst Rev. 2004;(4):CD000245. 

Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of appropriate antibiotic use for 

treatment of acute bronchitis in adults. Ann Intern Med. 2001;134:518-20. 

Guidelines for the Control of Pertussis Outbreaks 

National Immunization Program 



www.cdc.gov/nip/publications/pertussis/guide.htm 

Get Smart. Know When Antibiotics Work 

National Campaign for Appropriate Antibiotic Use 

Division of Bacterial and Mycotic Diseases 




www.cdc.gov/drugresistance/community/ 

120

TRAINING PROBLEM #16: ACUTE MYOCARDIAL INFARCTION 

RATIONALE: 

Cardiovascular disease is the number one killer of Americans. Many associated risk factors are 

quite modifiable. Proper urgent management of acute myocardial infarctions significantly reduces 

mortality. 





Anatomy and physiology of the heart and coronary vessels. 

Risk factors for and pathogenesis/pathophysiology of atherosclerosis. 

Pharmacology of aspirin, morphine, nitroglycerine, heparin, antiplatelet agents, thrombolytic 

agents, beta-blockers, angiotensin converting enzyme inhibitors (ACE-I), angiotensin II 

receptor blockers (ARB), and HMG-CoA reductase inhibitors. 



1. 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). (MK) 

2. The basic principles of the role of genetics in CAD. (MK) 

3. Pathogenesis, signs, and symptoms of the acute coronary syndromes: 

Unstable angina. (MK) 

Non-ST-elevation myocardial infarction (NSTEMI). (MK) 

ST-elevation myocardial infarction (STEMI). (MK) 

4. Atypical presentations of cardiac ischemia/infraction. (MK) 

5. The typical clinical course of the acute coronary syndromes. (MK) 

6. ECG findings and macromolecular markers (myoglobin, CK-MB, Troponin-I, Troponin-T) of 

acute ischemia/MI. (MK) 

7. The utility of echocardiography in acute MI. (MK) 

8. The importance of monitoring for and immediate treatment of ventricular fibrillation in acute MI. 

(MK) 

9. Therapeutic options for acute MI and how they may differ for NSTEMI and STEMI, including: 

Aspirin. (MK) 

Morphine. (MK) 

Nitroglycerine. (MK) 

Oxygen. (MK) 

Heparin. (MK) 

Antiplatelet agents (glycoprotein IIb/IIIa inhibitors). (MK) 

Beta-blockers. (MK) 

ACE-I/ARB. (MK) 

HMG-CoA reductase inhibitors. (MK) 

Thrombolytic agents. (MK) 

121

Emergent cardiac catheterization with percutaneous coronary intervention. (MK) 

10. 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. (MK) 

11. The general approach to the evaluation and treatment of ventricular tachycardia and fibrillation. 

(MK) 

12. The importance of post-MI risk stratification, including the burden of residual coronary disease 

and assessment of left ventricular function. (MK) 

13. Basic principles of cardiac rehabilitation. (MK) 

14. Indications for coronary artery bypass grafting (CABG). (MK) 

15. The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on the 

Accreditation of Healthcare Organizations (JCAHO) quality measures for acute MI treatment. 

(MK, PLI, SBP) 




Cardiac risk factors. (PC, CS) 

Location, duration, intensity, exacerbating/ameliorating factors, radiation of chest pain. (PC, 

CS) 

Symptoms associated with chest pain (e.g. nausea, emesis, dyspnea, diaphoresis, 

palpitations, dizziness, syncope, heartburn belching, etc.). (PC, CS) 



Recognition of dyspnea and anxiety. (PC) 

Accurate measurement of vital signs. (PC) 

Examination of the heart and vascular system. (PC) 

Examination of the lungs. (PC) 



etiology of chest pain: 

Stable angina. (PC, MK) 

Coronary vasospasm. (PC, MK) 

Unstable angina. (PC, MK) 

Acute MI. (PC, MK) 

Pericarditis. (PC, MK) 

Aortic dissection. (PC, MK) 

Pulmonary embolism. (PC, MK) 

Other noncardiac causes of chest pain. (PC, MK) 




characteristics as well as patient preferences 


ECG. (PC, MK) 


Macromolecular markers (myoglobin, CK-MB, Troponin-I, Troponin- T). (PC, MK) 


122

esults of: 

Echocardiogram. (PC, MK) 

Cardiac stress testing. (PC, MK) 




CS) 

Elicit questions from the patient and his or her family about the diagnostic and management 


Educate patients about modifying cardiac risk factors. (PC, CS) 



Medical management of acute MI. (PC, MK) 

CCU monitoring. (PC, MK) 

Indications for and complications of thrombolytic therapy, cardiac catheterization with 

percutaneous coronary intervention, and CABG. (PC, MK) 

Proper pre-discharge risk stratification. (PC, MK) 

Secondary risk factor modification. (PC, MK) 

Determining when to obtain consultation from a cardiologist and cardiothoracic surgeon. 

(PC, SBP) 



issues related to acute MI. (PC, PLI) 



1. Demonstrate a commitment to meeting national quality standards for the care of 

patient with acute MI. (P, PLI, SBP) 


considerations in the selection diagnostic and therapeutic interventions for acute MI. (PLI, P) 


and therapeutic options for acute MI. (P) 

4. Demonstrate ongoing commitment to self-directed learning regarding acute MI. (PLI, 

P) 

5. Appreciate the impact acute MI has on a patient’s quality of life, well-being, ability to 

work, and the family. (P) 


other healthcare professionals in the treatment of acute MI. (P, SBP) 


ACC/AHA 2002 guideline update for the management of patients with chronic stable 

angina--summary article: a report of the American College of Cardiology/American 

Heart Association Task Force on practice guidelines (Committee on the Management 

of Patients with Chronic Stable Angina). J Am Coll Cardiol 2003; 41:159-68. 

www.acc.org/clinical/topic/topic.htm#guidelines 

ACC/AHA 2002 guideline update for the management of patients with unstable 

angina and non-ST-segment elevation myocardial infarction-summary article: a report 

123

of the American College of Cardiology/American Heart Association task force on 

practice guidelines (Committee on the Management of Patients With Unstable 

Angina). J Am Coll Cardiol. 2002;40:1366-74. 


ACC/AHA guidelines for the management of patients with ST-elevation myocardial 

infarction--executive summary. A report of the American College of 

Cardiology/American Heart Association Task Force on Practice Guidelines (Writing 

Committee to revise the 1999 guidelines for the management of patients with acute 

myocardial infarction). J Am Coll Cardiol. 2004;44:671-719. 

Erratum in: J Am Coll Cardiol. 2005;45(8):1376. 


AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and 

death in patients with atherosclerotic cardiovascular disease: 2001 update: A 

statement for healthcare professionals from the American Heart Association and the 

American College of Cardiology. Circulation. 2001;25:1577-9. 


124

TRAINING PROBLEM #17: ACUTE RENAL FAILURE AND 

CHRONIC KIDNEY DISEASE 

RATIONALE: 

Renal disease is a common problem in internal medicine and may manifest with symptoms 

referable to the kidney as well as other systems. Patients who go on to end-stage renal disease 

have high morbidity and mortality, despite advances in dialysis treatment. Thus, an understanding 

of chronic kidney disease is useful to all physicians. A rational approach to patients with suspected 

or known acute renal failure allows students and clinicians to quickly assess the etiology and initiate 

treatment without unnecessary delay in an effort to prevent the development of chronic kidney 

disease. 





Knowledge of pathogenesis and pathophysiology of acute renal failure and the development of 

chronic kidney disease. 

Understanding of drugs that can have adverse effect on renal function. 



1. The distinction between the three major pathophysiologic etiologies for acute renal failure 

(ARF): 

Decreased renal perfusion (prerenal). (MK) 

Intrinsic renal disease (renal). (MK) 

Acute renal obstruction (postrenal). (MK) 

2. The pathophysiology of the major etiologies of “prerenal” ARF, including: 

Hypovolemia. (MK) 

Decreased cardiac output. (MK) 

Systemic vasodilation. (MK) 

Renal vasoconstriction. (MK) 

3. The pathophysiology of the major etiologies of intrinsic “renal” ARF, including: 

Vascular lesions. (MK) 

Glomerular lesions. (MK) 

interstitial nephritis. (MK) 

Intra-tubule deposition/obstruction. (MK) 

Acute tubular necrosis (ATN). (MK) 

4. The pathophysiology of the major etiologies of “postrenal” ARF, including: 

Urethral (e.g. tumors, calculi, clot, sloughed papillae, retroperitoneal fibrosis, 

lymphadenopathy). (MK) 

Bladder neck (e.g. tumors, calculi, prostatic hypertrophy or carcinoma, neurogenic). (MK) 

Urethral (e.g. stricture, tumors, obstructed indwelling catheters). (MK) 

125

5. The pathophysiology and clinical findings of uremia. (MK) 

6. The natural history, initial evaluation and treatment, and complications of ARF. (MK) 

7. The most common etiologies of chronic kidney disease (CKD): 

DM. (MK) 

Hypertension. (MK) 

Glomerulonephritis. (MK) 

Polycystic kidney disease. (MK) 

Autoimmune diseases (e.g. systemic lupus erythematosus). (MK) 

The staging scheme for CKD. (MK) 

8. The significance for proteinuria in CKD. (MK) 

9. The use of ACE-Is and ARBs in the management of CKD. (MK) 

10. The importance of secondary hyperparathyroidism in CKD. (MK) 

11. The pathophysiology of anemia in CKD. (MK) 

12. The value of glycemic and hypertension control in limiting the progression of CKD. 

(MK) 

13. The value of CAD risk factor modification in patients with CKD, particularly those 

treated with dialysis. (MK) 

14. The basic principles of renal replacement therapy (e.g., hemodialysis and peritoneal 

dialysis) as well as the complications. (MK) 


1 History-taking skills: Students should be able to obtain, document, and present an ageappropriate 

history that distinguishes among the three major reasons for ARF (pre-renal, renal, 

post-renal), including the predisposing conditions, nephrotoxic drugs or agents, and systemic 

disease and the major causes of CKD. (PC, CS) 

2. Physical exam skills: Students should be able to perform a physical examination to establish 

the diagnosis and severity of disease, including: 

The determination of a patient’s volume status through estimation of the central venous 

pressure using the height of jugular venous distention and measurement of pulse and blood 

pressure in the lying/standing position. (PC) 

Palpation and percussion of the bladder to recognize bladder distention. (PC) 

Palpation of the prostate. (PC) 

Determination of the presence of pulmonary edema, peripheral edema, ascites, and signs 

of heart failure. (PC) 

Findings consistent with uremia. (PC) 

Examination for evidence of systemic disease, including but not limited to: skin, joints, and 

nails. (PC) 

3. Differential diagnosis: Students should be able to generate a differential diagnosis for a 

patient with ARF or CKD recognizing specific history, physical exam, and laboratory findings 

that suggest a specific etiology. (PC, MK) 






Serum electrolytes, BUN/Cr, calcium, phosphorus. (PC, MK) 

Urine sodium. (PC, MK) 


126

Anion gap. (PC, MK) 

ABG (PC, MK) 

Serum BUN to Cr ratio. (PC, MK) 

CBC, ferritin. (PC, MK) 

Performing and interpreting a urinalysis, including microscopic examination for casts, red 

blood cells, white blood cells, and crystals. (PC, MK) 

Calculating fractional excretion of sodium and appreciate its usefulness in distinguishing 

between pre-renal and intrinsic renal disease. (PC, MK) 

Calculating creatinine clearance using the Cockcroft-Gault or MDRD (“modification of diet 

in renal disease study”) equations. (PC, MK) 

Serum parathyroid hormone level. (PC, MK) 

ECG findings in hyperkalemia. (PC, MK) 



Renal ultrasonography. (PC, MK) 





Counsel patients regarding a renal diet. (PC, CS) 


Insert a peripheral intravenous catheter. (PC) 

Place a urinary catheter. (PC) 



treatment plan for patients, including: 

Designing an appropriate management plan for initial management of ARF, including 

volume management, dietary recommendations, drug dosage alterations, electrolyte 

monitoring, and indications for dialysis. (PC, MK) 

Developing a management plan to effectively treat HTN and DM. (PC, MK) 

Recommending treatment with phosphate binders, calcium replacement, and vitamin D 

replacement. (PC, MK) 

Recommending treatment for dyslipidemia. (PC, MK) 

Recommending treatment for anemia secondary to CKD. (PC, MK) 

Recommending acute treatment for hyperkalemia. (PC, MK) 

Determining when to obtain consultation from a nephrologist. (PC, MK) 



issues related to renal failure. (PC, PLI) 



3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence-based considerations in 

the selection of diagnostic and therapeutic interventions for ARF and CKD. (PLI, P) 

4. Respond appropriately to patients who are nonadherent to treatment for renal failure. (CS, P) 

5. Demonstrate ongoing commitment to self-directed learning regarding renal failure. (PLI, P) 

4. Appreciate the impact renal failure has on a patient’s quality of life, wellbeing, ability to work, 

127



professions in the treatment of renal failure. (P, SBP) 


11. 

Lamiere N, Van Breson W, Vanholder R. Acute renal failure. Lancet. 2005;365:417-30. 

Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA. 2003;289:747-51. 

Schrier RW, Wang W, Poole B, Mitra A. Acute renal failure: definitions, diagnosis, 

pathogenesis, and therapy. J Clin Invest. 2004;114:5-14. 

Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis. Ann Intern 

Med. 2002;137:744-52. 

Levey AS. Clinical practice. Nondiabetic kidney disease. N Engl J Med. 2002;347:1505- 

Palmer BF. Renal dysfunction complicating the treatment of hypertension. N Engl J 

Med. 2002;347:1256-61. 

128

TRAINING PROBLEM #18: COMMON CANCERS 

RATIONALE: 

A skillful initial workup for suspected cancer is an essential part of effective primary care practice. 

Developing a logical and practical diagnostic approach to the more common cancers (e.g. skin, 

colorectal, lung, breast, cervical, and prostate) is an excellent means of honing basic history-taking, 

physical examination, and communication skills and learning how to use diagnostic studies in a cost 

effective manner. Encountering patients in whom cancer is a diagnostic possibility will stimulate 

learning of the important clinical presentations and natural histories of these life-threatening 

conditions. Focusing on cancer diagnosis helps to concentrate the student’s learning and avoids 

premature immersion in the often very technical and specialized issues of cancer treatment. 





Anatomy, physiology, and pathophysiology of common cancers. 

Basic knowledge of the common symptoms and signs of the most common cancers. 

Knowledge of basic concepts of clinical epidemiology pertinent to test selection and 

interpretation (e.g. sensitivity, specificity, positive predictive value, negative predictive value). 



3. Primary prevention measures for common cancers. (MK) 

4. Current screening recommendations for skin, colorectal, lung, breast, cervical, and 

prostate cancer. (MK) 

3. Principle clinical presentations, clinical courses, complications, and causes of death for the 

most common cancers (e.g. skin, colorectal, lung, breast, cervical, and prostate). (MK) 

4. Basic methods of initial evaluation, including the sensitivity and specificity of basic diagnostic 

studies and indication for their use, including: 

Indications for skin biopsy in a patient with a suspicious skin lesion. (MK) 

Indications for colonoscopy in individuals a risk for colon cancer. (MK) 

Indications for breast biopsy in a patient with a breast nodule or abnormal screening 

mammogram. (MK) Indications for a lymph node biopsy in a patent with suspicious 

lymphadenopathy. (MK) 

Initial cost-effective workups for: isolated pleural effusion, pulmonary nodule, liver nodule, 

prostate nodule, elevated prostate-specific antigen, testicular nodule, stool test positive for 

occult blood, abnormal 

Pap smear, and other findings suggestive of gastrointestinal and urogenital cancers. 

(MK) 

5. Genetic considerations of selected cancers (e.g. hereditary nonpolyposis colon cancer, familial 

adenomatous polyposis, BRCA1/BRCA2, HER2, Philadelphia chromosome/BRC-ABL). (MK) 

6. The role of human papilloma virus in cervical cancer. (MK) 

7. The similarities and differences between curative and palliative cancer care. (MK) 

8. The principles of palliative care and hospice care. (MK) 

9. Symptoms sometimes seen during end-of-life care and the basic principles of their 

129

management (e.g., pain, dyspnea, nausea and vomiting, anorexia, fatigue, depression, 

delirium, constipation). (MK) 




including: 

Unintentional weight loss, fever, bone pain. (PC, CS) 

Sun exposure history, abnormal skin lesions. (PC, CS) 

Blood in the stool, alterations in bowel movements, abdominal pain, abdominal mass. (PC, 

CS) 

Smoking, cough, hemoptysis, chest pain, dyspnea. (PC, CS) 

Breast nodules and secondary signs of breast cancer. (PC, CS) 

Abnormal vaginal bleeding. (PC, CS) 

Abnormal urinary symptoms. (PC, CS) 

Lymphadenopathy. (PC, CS) 



Skin examination. (PC) 

Digital rectal examination. (PC) 

Breast examination. (PC) 

Lymph node examination. (PC) 

Male genital examination and prostate examination. (PC) 

Pelvic examination and Pap smear. (PC) 



etiology for: 

Unintentional weight loss. (PC, MK) 

Fever. (PC, MK) 

Abnormal skin lesions. (PC, MK) 

Occult blood positive stool. (PC, MK) 

Colorectal mass. (PC, MK) 

Chronic cough, hemoptysis, pulmonary nodule, and pleural effusion. (PC, MK) 

Breast mass. (PC, MK) 

Abnormal Pap smear. (PC, MK) 

Abdominal or pelvic mass. (PC, MK) 

Prostate nodule and elevated prostate specific antigen. (PC, MK) 

Lymphadenopathy. (PC, MK) 


diagnostic and laboratory tests and be able to interpret them, both prior to and after 

initiating treatment based on the differential diagnosis, including consideration of test 

cost and performance characteristics as well as patient preferences. 


CBC. (PC) 

Electrolytes, BUN/Cr, Ca, hepatic function panel. (PC) 


PSA. (PC) 

130


significance of the results of: 

Skin biopsy. (PC) 

Mammogram. (PC) 

Breast biopsy. (PC) 

Colon/rectal biopsy. (PC) 

Lung biopsy. (PC) 

Pap smear. (PC) 

Prostate biopsy. (PC) 

Lymph node biopsy. (PC) 


Communicate the diagnostic plan and subsequent follow-up to patients. (PC, CS) 


With guidance and direct supervision, participate in breaking bad news to patients. (PC, 

CS) 

With guidance and direct supervision, participate in discussing basic issues regarding 

advance directives with the patient and his or her family. (PC, CS) 

With guidance and direct supervision participate in discussing basic end-of-life issues with 

the patient and his or her family. (PC, CS) 


Cervical Pap smear. (PC) 




Initial work-up of the symptom, sign, or abnormal laboratory value suspected to be due to 

cancer. (PC) 

Provision of support and information for the patient. (PC) 

Coordination of care for workup. (PC, SBP) 

Determining when to obtain consultation from appropriate specialists. (PC, SBP) 

A cost-effective approach based on the differential diagnosis. (PC, SBP) 


issues related to common cancers. (PC, PLI) 

Incorporating patient needs and preferences. (PC, P) 

Appropriately assessing and treating pain when necessary with nonnarctoic and narcotic 

analgesics. (PC) 

Anticipating and treating narcotic side effects if necessary. (PC) 

Adjusting the therapeutic plan when goals of care change (e.g., a shift toward palliative 

care). (PC) 

Alleviation of symptoms sometimes seen during end of life care (e.g., pain, dyspnea, 

nausea and vomiting, anorexia, fatigue, depression, delirium, constipation). (PC) 

Utilizing supportive care or hospice service when appropriate. (PC, SBP) 


1. Appreciate the uncertainty and fear patients experience when cancer is a significant diagnostic 

possibility. (P) 

2. Respect the patient’s right to refuse cancer screening. (P) 


131

considerations in the selection diagnostic and therapeutic interventions for common cancers. (PLI, P) 

4. Recognize the importance of patient preferences when selecting among diagnostic options for 

common cancers. (P) 

5. Demonstrate ongoing commitment to self-directed learning regarding common cancers. (PLI, 

P) 

6. Appreciate the impact common cancers have on a patient’s quality of life, well-being, ability to 



healthcare professions in the workup and treatment of common cancers. (P, SBP) 


National Cancer Institute 

National Institutes of Health 

www.cancer.gov 

Guide to Clinical Preventive Services 

U.S. Preventative Services Task Force (USPSTF) 

Agency for Healthcare Research and Quality 


www.ahrq.gov/clinic/cps3dix.htm#cancer 

American Cancer Society 

www.cancer.org 

NCCN Clinical Practice Guidelines in Oncology National Comprehensive 

Cancer Network 

www.nccn.org/professionals/physician_gls/default.asp 

132

TRAINING PROBLEM #19: COPD/OBSTRUCTIVE AIRWAYS 

DISEASE 

RATIONALE: 

The chronic obstructive pulmonary diseases (chronic bronchitis and emphysema) are important 

causes of morbidity and mortality and are a major cause of total disability, second only to coronary 

artery disease. Cigarette smoking plays a major role in the progression of the disease, with survival 

rates lower among patients who continue to smoke cigarettes. The severity and debilitation of these 

disorders make them an important training problem for all third year medical students. The number 

of new cases of asthma is dramatically increasing. Most cases with appropriate treatment can have 

minimal symptoms. 





Normal structure and function of the heart and lungs and how these are altered in respiratory 

system diseases. 

Pathogenesis and pathophysiology of pulmonary diseases. 

Pharmacology of bronchodilators, corticosteroids, and antibiotics. 



1. The epidemiology, risk factors, symptoms, signs, and typical clinical course of the common 

forms of COPD, including chronic bronchitis and emphysema. (MK) 

2. Common causes of acute exacerbations of COPD (AECOPD), including: 

Acute infectious bronchitis. (MK) 



Poor air quality (e.g. ozone, pollutants, tobacco smoke). (MK) 

Occupational exposures. (MK) 

Medical noncompliance. (MK) 

3. The etiology, pathogenesis, evaluation, and management of hypoxemia and hypercapnia. 

(MK) 

4. The genetics and role of alpha-1 antitrypsin deficiency in some patients with emphysema. (MK) 

5. The epidemiology, risk factors, symptoms, signs, and typical clinical course of asthma. (MK) 

6. Allergic and non-allergic factors that may precipitate bronchospasm and exacerbate asthma, 

including: 

Grass and tree pollen. (MK) 

Animal dander. (MK) 

Cockroaches. (MK) 

Dust mites. (MK) 

Allergic rhinitis/post-nasal drip. (MK) 

133

Acute/chronic infectious sinusitis. (MK) 

Acute infectious bronchitis. (MK) 



Exercise. (MK) 

Anxiety/stress. (MK) 

Poor air quality (e.g. ozone, pollutants, tobacco smoke). (MK) 

Occupational exposures. (MK) 

Medical noncompliance. (MK) 

7. Therapies for COPD and asthma, including: 

Beta-agonist bronchodilators. (MK) 

Anticholinergic bronchodilators. (MK) 

Leukotriene inhibitors. (MK) 

Mast cell stabilizers. (MK) 

Theophylline. (MK) 

Inhaled corticosteroids. (MK) 

Systemic corticosteroids. (MK) 

Antimicrobial agents. (MK) 

Supplemental oxygen. (MK) 

Immunotherapy. (MK) 

8. The indications for and the efficacy of influenza and pneumococcal vaccines. 

(MK) 



medical history, that differentiates among etiologies of disease including: 

Existence, duration, and severity of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, 

cough, sputum production, wheezing, fever, chills, sweats, chest pain, hemoptysis. (PC, 

CS) 

Smoking history and passive exposure to tobacco smoke. (PC, CS) 

Occupational history. (PC, CS) 

Family history of pulmonary problems. (PC, CS) 




Assessing the use of accessory muscles for breathing. (PC) 

Identifying bronchial breath sounds, rales, rhonchi, and wheezes. (PC) 

Identifying signs of pulmonary consolidation, pleural effusion, and pneumothorax. (PC) 

Identifying the signs of pulmonary hyperresonance/hyperexpansion. (PC) 


recognizing specific history and physical exam findings that suggest a diagnosis of chronic 

bronchitis, emphysema, asthma, or other conditions with similar findings. 






134

Pulse oximitry. (PC, MK) 

ABG. (PC, MK) 







Counsel patients about smoking cessation. (PC, CS) 

Counsel patients about the performance of home peak flow monitoring. (PC, CS) 

Counsel patients about environmental controls. (PC, CS) 

Encourage asthma patients to be involved in their own disease management and counsel 

them about an “asthma action plan.” (PC, CS) 





The use of bronchodilators and inhaled corticosteroids. (PC, MK) 

The key components of the care of patients admitted with acute exacerbations of COPD 

and asthma. (PC, MK) 

Using systemic corticosteroids appropriately. (PC, MK) 

Judicious use of antimicrobial agents. (PC, MK) 

The principles of oxygen therapy. (PC, MK) 

Determining when to obtain consultation from a pulmonologist or allergist/immunologist. 

(PC, SBP) 

Smoking cessation strategies. (PC) 



issues related to COPD and asthma. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for COPD and asthma. 

(PLI, P) 


therapeutic options for COPD and asthma (P) 

3 Respond appropriately to patients who are nonadherent to treatment for COPD and asthma. 

(CS, P) 

4 Appreciate the impact of working, living, and environmental conditions on the development and 

progression of respiratory tract disease; demonstrate understanding that patients are often 

unable to change these factors on their own. (P) 

5 Demonstrate ongoing commitment to self-directed learning regarding COPD and asthma. (PLI, 

P) 

6 Appreciate the impact COPD and asthma have on a patient’s quality of life, well-being, ability 

to work, and the family. (P) 


healthcare professionals in the diagnosis and treatment of COPD and asthma. (P, SBP) 

135

8 Appreciate the importance of antimicrobial resistance. (P) 

9. Show understanding for the difficulties patients face with smoking cessation. (P) 


National Heart Lung and Blood Institute/World Health Organization Global Initiative for 

Chronic Obstructive Lung Disease Diagnosis, management, and prevention of chronic 

obstructive pulmonary disease 

www.goldcopd.com 

National Institutes of Health, National Heart, Lung, and Blood Institute National Asthma 

Education and Prevention Program Practical Guide for the Diagnosis and Management 

of Asthma NIH Publication 97-4074. Bethesda, MD. 2003. 

http://www.nhlbi.nih.gov/health/indexpro.htm 

Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with 

COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932-46. 

136

TRAINING PROBLEM #20: DIABETES MELLITUS 

RATIONALE: 

Diabetes mellitus is an increasingly prevalent illness in the United States. It is estimated that five to 

nine percent of American adults are diabetic with the illness appearing at earlier ages in some 

populations. It is a leading cause of disability and death. Over 130 billion health care dollars are 

spent on diabetes annually. All internists must identify those at risk and institute appropriate 

management to ameliorate the potentially fatal complications of this illness. 





Pathogenesis and pathophysiology of type I and II diabetes mellitus, diabetic ketoacidosis, 

nonketotic hyperglycemia. 

Effects of insulin on glucose and fat metabolism. 

Pharmacology of insulin, sulfonylureas, metformin, thiazolidinediones, and glucose absorption 

inhibitors. 



1. Diagnostic criteria for impaired fasting glucose and impaired glucose tolerance. (MK) 

2. Diagnostic criteria for type I and type II diabetes mellitus, based on a history, physical 

examination, and laboratory testing. (MK) 

3. Pathophysiology, risk factors, and epidemiology of type I and type II diabetes mellitus. (MK) 

4. The basic principles of the role of genetics in diabetes mellitus. (MK) 

5. Presenting symptoms and signs of type I and type II diabetes mellitus. (MK) 

6. Presenting symptoms and signs of diabetic ketoacidosis (DKA) and nonketotic hyperglycemic 

(NKH). (MK) 

7. Pathophysiology for the abnormal laboratory values in DKA and NKH including plasma 

sodium, potassium, and bicarbonate. (MK) 

8. Precipitants of DKA and NKH. (MK) 

9. 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). (MK) 

10. 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. (MK) 

11. Non-pharmacologic and pharmacologic (drugs and side effects) treatment of diabetes mellitus 

to maintain acceptable levels of glycemic control, prevent target organ disease, and other 

associated complications. (MK) 

12. The specific components of the American Diabetes Association (ADA) dietary recommendations 

for type I and type II diabetes mellitus. (MK) 

13. Basic management of diabetic ketoacidosis and nonketotic hyperglycemic states, including the 

similarities and differences in fluid and electrolyte replacement. (MK) 

14. Basic management of blood glucoses in the hospitalized patient. (MK) 

137

15. The Somogyi effect and the Dawn phenomenon and the implications of each in diabetes 

pharmacologic management. (MK) 

16. The fundamental aspects of the American Diabetes Association (ADA) clinical practice 

recommendations and how they encourage high quality diabetes care. (MK, PLI, SBP) 

17. Basic management of hypertension and hyperlipidemia in the diabetic patient. (MK) 




including: 

Weight changes. (PC, CS) 

Hypo- or hyperglycemic symptoms. (PC, CS) 

Medication history (adherence, side effects, other medications). (PC, CS) 

Home glucose monitoring results. (PC, CS) 

Target organ disease complications (cardiovascular, foot, gastrointestinal, infectious, 

neurological, sexual, skin, urinary, or vision symptoms). (PC, CS) 

Diet history (total caloric intake, intake of sugar-containing foods, intake of saturated fat and 

cholesterol, physical activity level, timing of meals). (PC, CS) 



Skin examination for diabetic dermopathy, furuncles/carbuncles, candidiasis, necrobiosis 

lipoidica diabeticorum, dermatophytosis, and acanthosis nigricans. (PC) 

Fundoscopic exam. (PC) 

Arterial pulses. (PC) 

Peripheral nerves (e.g. monofilament testing). (PC) 

Examination of the feet for corns, calluses, and ulcerations. (PC) 

In patients with DKA or NKH evaluate for mental status alterations, Kussmaul’s 

respirations, fruity breath, and signs of volume depletion. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology for: 

Hyperglycemia. (PC, MK) 

Hypoglycemia. (PC, MK) 

Anion gap acidosis. (PC, MK) 

Ketosis. (PC, MK) 

Hyperosmolality. (PC, MK) 




characteristics as well as patient preferences Laboratory and diagnostic tests should include, 


Fasting serum GLC. (PC, MK) 

Electrolytes, BUN/Cr. (PC, MK) 

Serum and urine ketones. (PC, MK) 


HbA1c. (PC, MK) 

Fasting lipid profile. (PC, MK) 

UA. (PC, MK) 

Urine microalbumin/creatinine ratio. (PC, MK) 

138

24-hour urine for protein and creatinine clearance. (PC, MK) 



CS) 

Elicit questions from the patient and their family about the management plan. (PC, CS) 

Counsel patients appropriately on dietary measures, exercise, medication adherence, 

proper foot care, and prevention of other target organ disease. (PC, CS) 


Finger-stick capillary blood glucose determination. (PC) 




Writing appropriate fluid and insulin orders and outline critical steps for the treatment of 

DKA and DKH. (PC, MK) 

Counseling patients regarding basic features of ADA diabetic diet recommendations. (PC, 

CS) 

Instructing patients in home blood glucose monitoring. (PC, CS) 

Counseling patients on behavior changes (smoking cessation, medication adherence, poor 

glycemic control, obesity, hypertension, dyslipidemia, and infection) to avoid the 

complications of diabetes. (PC, CS) 

Counseling patients regarding basic foot care. (PC, CS) 

Determining when to institute diet therapy, oral hypoglycemic agents, and insulin therapy. 

(PC, MK) 

Calculating an appropriate insulin dose for a diabetic patient. (PC, MK) 

Using community resources (ADA, hospital and community-based education programs) to 

aid the patient in understanding and managing his or her illness. (PC, SBP) 

Determining when to obtain consultation from an endocrinologist, nephrologist, 

ophthalmologist, podiatrist, and dietician. (PC, SBP) 


issues related to diabetes mellitus. (PC, PLI) 

Incorporating patient preferences. (PC) 


1. Demonstrate a commitment to meeting ADA clinical practice 

recommendations to insure quality diabetes care. (PLI, P, SBP) 

2. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence-based considerations in 

the selection diagnostic and therapeutic interventions for diabetes mellitus. (PLI, P) 


therapeutic options for diabetes mellitus. (P) 

4. Respond appropriately to patients who are nonadherent to treatment for diabetes mellitus. (CS, P) 

5. Demonstrate ongoing commitment to self-directed learning regarding diabetes mellitus. (PLI, P) 

6. Appreciate the impact diabetes mellitus has on a patient’s quality of life, wellbeing, ability to work, 


7. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare 

professionals in the treatment of diabetes mellitus. (P, SBP) 


139

The Diabetes Control and Complication Trail Research Group. The effect of intensive 

treatment of diabetes on the development and progression of long-term complications in 

insulin-dependent diabetes mellitus. N Engl JMed. 1993;329:977-86. 

UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with 

sulphonylureas or insulin compared with conventional treatment and risk of 

complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-53. 

Clinical Practice Recommendations American Diabetes Association 

www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp 

Kitabchi AE. Wall BM. Management of diabetic ketoacidosis. Am Fam Physician. 

1999;60:455-64. 

140

TRAINING PROBLEM #21: DYSLIPIDEMIA 

RATIONALE: 

Dyslipidemia is a common, important, and treatable cardiovascular risk factor. Its pathophysiology is 

increasingly understood, diagnostic tests are readily available, and treatment modalities range from 

diet and exercise to a multitude of pharmacotherapies. Competency in the evaluation and 

management of this problem helps develop skills in rational test selection, patient education, and 

design of cost-effective treatment strategies. It also draws attention to the importance of community 

health education and nutrition. 





Anatomy and physiology of the vascular system. 

Basic cholesterol and lipoprotein metabolism. 

Pathogenesis and pathophysiology of atherosclerosis. 

Pharmacology of bile acid sequestrants (resins), nicotinic acid, fibric acid derivatives, HMG- 

CoA reductase inhibitors (statins), and cholesterol absorption inhibitors (ezetimibe). 



1 The contribution of lipoproteins to atherogenesis and CAD risk, including the importance of 

elevations in total cholesterol, LDL cholesterol, ratio of total to HDL cholesterol, and 

Lipoprotein a. (MK) 

2 The classification and etiologies of primary dyslipidemias. (MK) 

3 Etiologies and underlying pathophysiology of secondary dyslipidemias. (MK) 

4. The basic principles of the role of genetics in dyslipidemia, particularly familial combined 

hyperlipidemia. (MK) 

5. Screening recommendations for dyslipidemias in American adults. (MK) 

6. The importance of identifying and treating asymptomatic patients at high risk for CAD as 

aggressively as those with symptomatic disease. (MK) 

7. The available diagnostic studies and their use, particularly determinations of HDL, LDL, and total 

cholesterol, as well as the need to test for other cardiovascular risk factors. (MK) 

8. The current National Cholesterol Education Program (NCEP, ATP III) guidelines for risk factor 

assessment, diagnosis and management of dyslipidemias, including goal LDL cholesterol, goal 

non-HDL cholesterol, and the concept of coronary artery disease equivalent based on risk 

factors for coronary artery disease. (MK, PLI, SBP) 

9. Basic management of the common dyslipidemias, including diet, fiber, exercise, and 

risk/benefits/cost of drug therapy (statins, fibrates, ezetimide, nicotinic acid, resins). (MK) 

10. Diagnosis and implications of the “metabolic syndrome.” (MK) 


1. History-taking skills: Students should be able to obtain, document, and present an age- 

141

appropriate medical history, that differentiates among etiologies of disease including: 

Prior patient or family history of dyslipidemia. (PC, CS) 

Other coronary risk factors. (PC, CS) 

Family history of early cardiovascular disease. (PC, CS) 

Dietary fat, saturated fat, fiber, cholesterol, and refined carbohydrate intake. (PC, CS) 

Exercise habits. (PC, CS) 


Past history of established CAD, cerebral vascular disease, and other vascular disease. 

(PC, CS) 

Presence of symptoms of angina and peripheral vascular disease. (PC, CS) 

History of renal, hepatic, or myopathic disease. (PC, CS) 



Blood pressure elevation. (PC) 

Xanthomata. (PC) 

Atherosclerotic fundoscopic changes. (PC) 

Carotid or femoral bruits. (PC, CS) 

Diminished peripheral pulses. (PC) 


recognizing specific history and physical exam findings that suggest primary or secondary 

causes of dyslipidemia. (PC, CS) 







TSH (PC, MK) 

Fasting GLC, electrolytes, BUN/Cr. (PC, MK) 

Hepatic function panel. (PC, MK) 

CK. (PC, MK) 



CS) 


Counsel patients about dietary measures to reduce cholesterol and saturated fats. (PC, 

CS) 

Counsel patients about ways to increase exercise. (PC, CS) 

Counsel patients about other modifiable cardiovascular risk factors. (PC, CS) 



An individual treatment plan that follows the NCEP ATP III guidelines. (PC, MK) 

Lifestyle modification (diet, exercise). (PC, MK) 

Appropriate pharmacologic interventions, including bile acid sequestrants (resins), nicotinic 

acid, fibric acid derivatives, HMG-CoA reductase inhibitors (statins), and cholesterol 

absorption inhibitors (ezetimibe). (PC, MK) 

Monitoring for adherence and side effects due to pharmacologic management. (PC, MK) 

142

Laboratory response to therapy. (PC, MK) 

Identifying barriers that prevent patients from adhering to recommended dietary, exercise, 

and pharmacologic plans. (PC, MK) 

Determining when to obtain consultation from an endocrinologist, or dietician. (PC, SBP) 



issues related to dyslipidemia. (PC, PLI) 



1 Demonstrate a commitment to meeting NCEP ATP III guidelines to insure quality care of 

patients with dyslipidemia. (PLI, P, SBP) 

2 Appreciate the importance of encouraging patients to assume responsibility for modifying their 

diet and increasing their exercise level. (P, CS) 

3 Appreciate the difficulties and frustrations that patients and health care providers face with 

recommended dietary changes. (P) 


considerations in the selection diagnostic and therapeutic interventions for dyslipidemia. (PLI, 

P) 


therapeutic options for dyslipidemia. (P) 

6 Respond appropriately to patients who are nonadherent to treatment for dyslipidemia. (CS, P) 

7 Demonstrate ongoing commitment to self-directed learning regarding dyslipidemia. (PLI, P) 


healthcare professionals in the treatment of dyslipidemia. (P, SBP) 


National Institutes of Health, National Heart, Lung, and Blood Institute National 

Cholesterol Education Program Clinical Practice Guidelines for Cholesterol 

Management in Adults (ATP III) 

www.nhlbi.nih.gov/about/ncep 

Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood Institute; 

American College of Cardiology Foundation; American Heart Association. Implications 

of recent clinical trials for the National Cholesterol Education Program Adult Treatment 

Panel III guidelines. Circulation. 2004;110:227-39. 

Ashen MD, Blumenthal RS. Clinical practice. Low HDL cholesterol levels. N Engl J 

Med. 2005;353:1252-60. 

Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J 

Med. 2005;352:1685-95. 

143

TRAINING PROBLEM #22: HEART FAILURE 

RATIONALE: 

Chronic heart failure (HF) is one of the most common cardiac problems encountered in clinical 

practice. Identification and correction of treatable underlying causes, control of precipitating factors 

and judicious use of multi-drug regimens for individuals with HF are important issues for third-year 

medical students. 


Prior knowledge, skills and attitudes acquired during the pre-clerkship years should include: 

Knowledge of the structure and function of the heart and lungs. 

Understanding of the epidemiology of heart disease. 

Knowledge of the atherogenesis and pathophysiology of cardiovascular disease. 

Knowledge of the pharmacology of cardiovascular drugs. 

Ability to communicate appropriately with all types of patients including the elderly and those 

with diverse backgrounds. 


Ability to perform a cardiovascular risk assessment and understand issues related to primary 

and secondary prevention of cardiovascular disease. 

Ability to understand the impact of illness on individuals and their families and, when 

appropriate, to address issues related to end-of-life care. 



1. Types of processes and most common disease entities that cause HF (i.e. ischemic, valvular, 

hypertrophic, infiltrative, inflammatory, etc.). (MK) 

2. The basic role of genetics in certain forms of cardiomyopathy. (MK) 

3. Staging system for heart failure: 

Stage A: high risk for HF but no structural heart disease is present. (MK) 

Stage B: structural heart disease is present but never any symptoms. (MK) 

Stage C: past or current symptoms associated with structural heart disease. (MK) 

Stage D: end-stage disease with requirements for specialized treatment. (MK) 

4. Types of processes that cause systolic vs. diastolic dysfunction. (MK) 

5. Symptoms and signs of left-sided vs. right-sided heart failure. (MK) 

6. Compensatory mechanisms of heart failure including cardiac remodeling and activation of 

endogenous neurohormonal systems. (MK) 

7. Factors leading to symptomatic exacerbation of HF, including ischemia, arrhythmias, 

hypoxemia, anemia, fever, hypertension, thyroid disorders, non-compliance with medications 

and dietary restrictions and use of nonsteroidal anti-inflammatory drugs. (MK) 

8. Importance of age, gender and ethnicity on the prevalence and 

prognosis of HF. (MK) 

9. Physiological basis and scientific evidence supporting each type 

of treatment, intervention, or procedure commonly used in the management of patients who 

present with HF. (MK) 

10. The general approach to the evaluation and treatment of atrial 

144

fibrillation (MK) 

11. Role of critical pathways or practice guidelines in delivering 

high-quality, cost effective care for patients presenting with new or recurrent heart failure. (PC, 

SBP) 

12. The Centers for Medicare & Medicaid Services (CMS) and the 

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) quality measures 

for HF treatment. (MK, PLI, SBP) 



age-appropriate medical history, including: 

Differentiating between various etiologies of heart failure (answers the question: Why is the 

patient in heart failure?). (PC, CS) 

Identifying clinical factors responsible for symptomatic exacerbation (answers the question: 

Why is the patient worse now?). (PC, CS) 

Exercise intolerance (fatigue, dyspnea on exertion). (PC, CS) 

Fluid retention (peripheral edema, dyspnea). (PC, CS) 

Changes in sleep pattern (orthopnea, paroxysmal nocturnal dyspnea [PND], nocturia). (PC, 

CS) 

Assessing the functional capacity of patients with HF (walking distance, New York Heart 

classification). (PC, CS) 

Cardiac risk factors. (PC, CS) 

2. Physical exam skills: Students should be able to perform a focused physical exam to 

help establish the diagnosis of HF and estimate its severity: 

Measurement of vital signs including weight and respiratory rate/pattern. (PC) 

Accurate measurement of arterial blood pressure and recognition of the typical blood 

pressure findings that occur in patients with aortic stenosis, aortic insufficiency and pulsus 

paradoxus. (PC) 

Assessment of major arterial pulses for abnormalities, including bruits. (PC) 

Assessment of the neck veins for jugular venous distention and, when necessary, 

evaluation for abdominal jugular reflux. (PC) 

Assessment of the conjunctiva and optic fundus. (PC) 

Assessment of the extremities to ascertain for skin conditions, including color, temperature 

and the presence of edema, cyanosis or clubbing. (PC) 

Assessment of the lungs for crackles, rhonchi and decreased breath sounds. (PC) 

Inspection and palpation of the anterior chest to identify right and left sided heaves, lifts and 

thrills. (PC) 

Auscultation of the heart to determine rhythm, intensity of heart sounds, splitting of S2 and 

the presence of rubs, gallops (S3, S4, summation) or extra heart sounds (e.g. clicks). (PC) 

Auscultation of the heart to detect the presence of heart murmurs; when a murmur is 

present, students should be able to: 

o Identify timing (systolic vs. diastolic, holosystolic vs. ejection). (PC) 

o Describe pitch, location and pattern of radiation. (PC) 

o Gauge significance (innocent vs. pathologic, sclerosis vs. stenosis). (PC) 

Assessment of the abdomen to determine the presence of hepatomegaly, 

ascites, abnormal pulsations and bruits. (PC) 


145

diagnosis and recognize specific history, physical exam and/or laboratory findings that: 

Help support or refute a clinical diagnosis of heart failure. (PC, MK) 

Distinguish between various underlying etiologies of HF, including disease processes that 

primarily affect: 

o Pericardium (constrictive pericarditis, pericardial tamponade). (PC, MK) 

o Endocardium (valvular [congenital, acquired], endocarditis). (PC, MK) 

o Myocardium (hypertrophic, restrictive, congestive). (PC, MK) 

4. Laboratory interpretation: Students should be able interpret specific diagnostic tests and 

procedures that are commonly ordered to evaluate patients who present with heart failure. 

Test interpretation should take into account: Laboratory and diagnostic tests should include, 




B-type natriuretic peptide. (PC, MK) 

Students should be able to define the indications for, and interpret (with consultation) the 

results of the following diagnostic tests and procedures: 


Treadmill and nuclear exercise testing. (PC, MK) 

Radionuclide ventriculogram. (PC, MK) 

Cardiac. (PC, MK) 



Communicate the diagnosis, prognosis and treatment plan to the patient and his or her 

family. (PC, CS) 


Educate patients about cardiovascular risk factors. (PC, CS) 

Council patients regarding a sodium-restricted diet. (PC, CS) 

Address palliative care and end-of-life issues with patients who have 

intractable symptoms associated with end-stage heart failure. (PC, CS, P) 

6. Basic and advanced procedural skills: students should be able to: 

Perform a 12-lead ECG. (PC) 




Recognize the importance of early detection and treatment of risk factors that may lead to 

the development of heart failure. (PC) 

Identifying the indications, contraindications, mechanisms of action, adverse reactions, 

significant interactions, and relative costs of the following treatments/interventions: 

o Non-pharmacological management. (PC, MK) 

-Sodium restriction. (PC, MK) 

-Physical activity and limitations. (PC, MK) 

o Pharmacological management (recommended for routine use). (PC, MK) 

-Diuretics. (PC, MK) 

-ACE-I/ARB. (PC, MK) 

-Beta-blockers. (PC, MK) 

-Aldosterone antagonists (spironolactone, eplerenone). (PC, MK) 

-digoxin. (PC, MK) 

o Interventions considered for use in selected patients. (PC, MK) 

-Hydralazine and isosorbide dinitrate. (PC,MK) 

146

-Angoitensin receptor blockers. (PC, MK) 

-Calcium channel blockers. (PC, MK) 

-Anti-arrhythmic agents. (PC, MK) 

-Anticoagulants/anti a thrombotic agents. (PC, MK) 

o other modalities(PC, MK) 

-Coronary revascularization. (PC, MK) 

-Synchronized biventricular pacing. (PC, MK) 

-Implantable cardiac defibrillators. (PC, MK) 

Developing a timely and appropriate evaluation and treatment plan for patients with heart 

failure due to diastolic dysfunction, including: 

o Control of physiologic factors (blood pressure, heart rate). (PC, MK) 

o Reduction in central blood volume by judicious use of diuretics. (PC, MK) 

o Alleviation of myocardial ischemia. (PC, MK) 

o Use of calcium channel blockers. (PC, MK) 

Describing use of other agents and interventions that may be useful in treating patients with 

refractory, end-stage heart failure: 

o Intravenous vasodilators. (PC, MK) 

o Intravenous positive inotropic agents. (PC, MK) 

o Infusion of B-type natriuretic peptide (nesiritide). (PC, MK) 

o Ventricular assist devices. (PC, MK) 

o Heart transplantation. (PC, MK) 

Defining and describing how the diagnosis and treatment of HF in special 

populations may differ (e.g. very elderly, associated co-morbidities). (PC, MK) 

Demonstrating how critical pathways or practice guidelines in ambulatory or hospitalized 

patients with HF can be used to guide diagnostic test ordering and medical decision 

making. (PC, PLI, SBP) 

Determining when to consult a cardiologist. (PC, SBP) 

Identifying when palliative care may be appropriate for patients with refractory symptoms 

associated with end-stage disease. (PC) 



issues related to HF. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for HF. (PLI, P) 

2. Recognize the significant morbidity and mortality associated with HF (P) 

3. Recognize the impact of lifestyle limitations caused by HF. (P) 

4. Respond appropriately to patients who are non-adherent to treatment for HF. (CS, P) 

5. Demonstrate ongoing commitment to self-directed learning regarding heart failure. (PLI, P) 


professions in the treatment of heart failure. (P, SBP) 

7. Appreciate the importance of and demonstrate a commitment to meeting national health care 

quality measures for the treatment of HF. (PLI, P, SBP) 

147


ACC/AHA 2005 guideline update for the diagnosis and management of chronic 

heart failure in the adult: a report of the American College of Cardiology/American 

Heart Association Task Force on Practice Guidelines (Writing Committee to 

Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). 

J Am Coll Cardiol. 2005;46:1116-43. 

http://www.acc.org/clinical/guidelines/failure/update/index.pdf 

Cook DJ, Simel DL. Does this patient have abnormal central venous pressure? JAMA. 

1996; 275: 630-634. 

Wang CS. FitzGerald JM. Schulzer M. Mak E. Ayas NT. Does this dyspneic patient in 

the emergency department have congestive heart failure? JAMA. 2005;294:1944-56. 

Doust JA. Glasziou PP. Pietrzak E. Dobson AJ. A systematic review of the diagnostic 

accuracy of natriuretic peptides for heart failure. Arch Intern Med. 2004;164:1978-84. 

Yan AT. Yan RT. Liu PP. Narrative review: pharmacotherapy for chronic heart failure: 

evidence from recent clinical trials. Ann Intern Med. 2005;142(2):132-45. 

Aurigemma GP. Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med. 

2004;351:1097-105. 

148

TRAINING PROBLEM #23: HIV INFECTION 

RATIONALE: 

HIV infection and AIDS represent one of the most difficult challenges in clinical medicine today. An 

HIV specialist (usually an infectious diseases physician) cares for the vast majority of patients with 

HIV infection and AIDS. Given that there is no proven cure, this remains an important training 

problem for third year medical students. The enormous and continuously evolving complexities of 

antiretroviral treatment are generally beyond the level of the third year medical student and for that 

matter most general internists. Rather, an approach to HIV infection, AIDS, and its most common 

and serious complications are stressed. 





Knowledge of the worldwide epidemiology, biology, and immunology of HIV. 

Microbiology of common opportunistic organisms. 

Pharmacology of antimicrobial agents and antiretrovirals. 

Understanding of universal precautions. 



1. Symptoms and signs of acute HIV seroconversion. (MK) 

2. CDC AIDS case definition. (MK) 

3. Specific tests for HIV (e.g. HIV ELISA, confirmatory western blot, quantitative PCR) and their 

operating characteristics. (MK) 

4. Relationship of CD4 lymphocyte count to opportunistic infections as well as relationship between 

CD4 lymphocyte count and viral load to overall disease progression. (MK) 

5. 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. (MK) 

6. Basics of post-exposure prophylaxis. (MK) 

7. The marked importance of antiretroviral medication adherence and the potential consequences of 

erratic or poor adherence. (MK) 

8. Vaccination recommendation for patients infected with HIV. (MK) 

9. Indications for and utility and risks of prophylaxis of HIV-related opportunistic infections. (MK) 

10. Pathogenesis, symptoms, signs, typical clinical course, and management of HIV-related 

opportunistic infections with a recognition of which are most common: 

Pneumocystis jiroveci. (MK) 

Candidiasis (oral, esophageal, vaginal). (MK) 

Cryptococcus neoformans. (MK) 

Cryptosporidium parvum. (MK) 

Cytomegalovirus infection (gastrointestinal, neurologic, retinal). (MK) 

Varicella-zoster virus. (MK) 

Isospora belli. (MK) 

149

Microsporidiosis. (MK) 

Mycobacterium avium complex. (MK) 

Mycobacterium tuberculosis. (MK) 

Toxoplasma gondii. (MK) 

11. Symptoms and signs of the following HIV-related malignancies: 

Kaposi’s sarcoma. (MK) 

Non-Hodgkin’s lymphoma. (MK) 

Cervical carcinoma. (MK) 

12. Common skin and oral manifestations of HIV infection and AIDS: 

Molluscum contagiosum. (MK) 

Cryptococcus neoformans. (MK) 

Viral warts. (MK) 

Lipodystrophy. (MK) 


Seborrhoeic dermatitis. (MK) 

Buccal candidiasis. (MK) 

Oral hairy leukoplakia. (MK) 

13. “Safe sex” practices (MK) 

14. The importance of proper ongoing dental care. (MK) 




HIV infection risk factors. (PC, CS) 

Sexual contacts. (PC, CS) 

Parenteral exposure to infected blood by needle sharing or transfusion. (PC, CS) 

Occupational exposures. (PC, CS) 

Other sexually transmitted diseases. (PC, CS) 

Tuberculosis exposure. (PC, CS) 

Prior HIV serology results, CD4 lymphocyte count and viral load. (PC, CS) 

Prior HIV-related opportunistic infections. (PC, CS) 

Current/prior antiretroviral medications and their side effects. (PC, CS) 

Fever, sweats, anorexia, unintentional weight loss, rash/skin lesions, lymphadenopathy. 

(PC, CS) 

Cough, sputum production, dyspnea, chest pain. (PC, CS) 

Headache, altered mental status, psychiatric complaints. (PC, CS) 

Odynophagia, dysphagia. (PC, CS) 

Vaginal discharge, history of cervical dysplasia or neoplasia. (PC, CS) 

Diarrhea. (PC, CS) 

Visual changes. (PC, CS) 

A dietary history to determine caloric intake. (PC, CS) 



General appearance regarding atrophy/wasting/cachexia. (PC) 

Complete neurologic examination. (PC) 

150

Mental status examination. (PC) 

Fundoscopic examination. (PC) 

Lymph node examination. (PC) 

Skin and oral examination. (PC) 

Pelvic and male genital examination. (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology in an 

potentially or known HIV-infected patient for the following: 

Fever. (PC, MK) 

Unintentional weight loss/wasting/cachexia. (PC, MK) 

Lymphadenopathy. (PC, MK) 

Rash and skin lesions. (PC, MK) 

Cough, sputum production, dyspnea, abnormal chest radiography. (PC, MK) 

Diarrhea, odynophagia, dysphagia. (PC, MK) 

Altered mental status and psychiatric changes. (PC, MK) 

Headache. (PC, MK) 

Oral lesions. (PC, MK) 

Visual/retinal abnormalities. (PC, MK) 






Specific tests for HIV (e.g. HIV ELISA, confirmatory western blot, quantitative PCR). (PC, 

MK) 

CD4 lymphocyte count. (PC, MK) 


Sputum staining and cultures. (PC, MK) 


Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell counts, staining, 

cultures, cytology, cryptococcal antigen, VDRL, 

Ebstein Barr virus, cytomegalovirus, toxoplasmosis, JC virus). (PC, MK) 

Stool for ova and parasites, cryptosporium, isospora, microsporidia, cytomegalovirus 

antigen. (PC, MK) 












counsel and educate patients about HIV exposure prevention (PC, CS) 

Counsel an exposed patient about seroconversion rates and, in appropriate situations, the 

availability of post-exposure prophylaxis. (PC, CS) 

151

Counsel and educate patients about complications of HIV drug therapy, drug-drug 

interactions, and the marked importance of adherence. (PC, CS) 


Obtain blood cultures. (PC) 



Assist in performing a lumbar puncture after explaining the procedure to the patient. (PC) 



Ordering appropriate laboratory tests. (PC, MK) 

Advising patients regarding HIV transmission prevention. (PC, MK) 

Insuring antiretroviral adherence. (PC, MK) 

Following parameters of disease progression/activity. (e.g. CD4 lymphocyte count, viral 

load). (PC, MK) 

Monitoring for the development of side effects from antiretroviral treatment and drug-drug 

interactions. (PC, MK) 

Insuring the administration of appropriate vaccinations. (PC, MK) 

Assessing PPD status. (PC, MK) 

Prescribing and monitoring appropriate opportunist infection prophylaxis. (PC, MK) 

Ordering nutritional supplements to manage and prevent malnutrition. (PC, MK) 

Assisting in the procurement of proper and ongoing dental care. (PC, MK) 

Identifying and recommending community health care resources available for the care of 

AIDS patients. (PC, SBP) 

Determining when to obtain consultation from an infectious diseases specialist. (PC, SBP) 



issues related to HIV infection and AIDS. (PC, PLI) 

Incorporating patient need and preferences. (PC) 


1. Appreciate the bioethical, social, and legal issues concerning patient confidentiality of HIV 

infection. (PC, CS) 

2. Demonstrate a nonjudgmental attitude regarding the mode of HIV acquisition. (P) 

3 Appreciate the sometimes severe social stigma of HIV infection and AIDS. (P) 

4 Show respect of “alternative lifestyles.” (P) 


considerations in the selection of diagnostic and therapeutic interventions for HIV infection and 

AIDS. (PLI, P) 

6 Recognize the importance of patient needs and preferences when selecting among diagnostic 

and therapeutic options for patients with HIV infection or AIDS. (P) 

7 Respond appropriately to patients who are nonadherent to antiretroviral treatment. (CS, P) 

8 Demonstrate ongoing commitment to self-directed learning regarding HIV infection and AIDS. 

(PLI, P) 

9 Appreciate the impact HIV infection and AIDS have on a patient’s quality of life, well-being, 


10 Recognize the importance of and demonstrate a commitment to the utilization of other health 

care professionals in the diagnosis and treatment of HIV infection and AIDS. (P, SBP) 

152


Guidelines for preventing Opportunistic Infections Among HIV-Infected Persons-2002. 

Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of 

America. MMWR 51(RR-08);1-60. Centers for Disease Control and Prevention 


www.cdc.gov/mmwr/PDF/RR/RR5108.pdf 

Guidelines for Using Antiretroviral Agents Among HIV-Infected Adults and Adolescents- 

2002. Recommendations of the Panel on Clinical Practices for Treatment of HIV. MMWR 

51(RR-07);1-64. 



www.cdc.gov/mmwr/PDF/RR/RR5107 

Aberg JA, Gallant JE, Anderson J, Oleske JM, Libman H, Currier JS, Stone VE, Kaplan, 

JE. Primary care guideline for the management of persons infected with human 

immunodeficiency virus: recommendation of the HIV Medicine Association of the Infectious 

Diseases Society of America. Clin Infect Dis. 2004;39:609-29. 

www.journals.uchicago.edu/CID/journal/issues/v39n5/34135/34135.web.p df 

www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=5625 

AIDSinfo National Institutes of Health 


www.aidsinfo.nih.gov 

Divisions of HIV/AIDS Prevention National Center for HIV, STD and TB Prevention Centers 

for Disease Control and Prevention U.S. Department of Health and Human Services 

www.cdc.gov/hiv/dhap.htm 

Hammer SM. Management of newly diagnosed HIV infection. N Engl J Med. 

2005;353:1702-10. 

153

TRAINING PROBLEM #24: HYPERTENSION 

RATIONALE: 

As many as 50 million Americans have elevated blood pressure (systolic pressure 140 mmHg or 

greater and/or diastolic blood pressure 90 mmHg or greater) or are taking antihypertensive 

medication. Nonfatal and fatal cardiovascular disease (CVD)— including coronary heart disease 

(CHD), peripheral vascular disease, stroke and renal disease—all increase progressively with higher 

levels of both systolic (SBP) and diastolic (DBP) blood pressure levels. These relationships are 

strong, continuous, independent, predictive and etiologically significant, and indicate that reduction of 

blood pressure reduces these risks. 


Prior knowledge, skills and attitudes acquired during the pre-clinical years should include: 



Knowledge of the pathogenesis and pathophysiology of hypertension. 

Knowledge of the epidemiology and risk factors for hypertension. 

Understanding of the pharmacologic management of acute and chronic hypertension. 

Understanding the behavioral issues by sex, race, culture, and age that relate to the 

management and treatment of hypertension. 



1. The etiologies and relative prevalence of primary and secondary hypertension. (MK) 

2. The basic principles of the role of genetics in hypertension. (MK) 

3. The definition of hypertensive urgency and emergency, citing examples of both. (MK) 

4. The difference between essential (primary) and secondary hypertension. (MK) 

5. Symptoms and signs of the following disorders associated with secondary hypertension: 

Renovascular hypertension. (MK) 

Renal failure. (MK) 

Polycystic kidney disease. (MK) 

Cushing’s disease or syndrome. (MK) 

Hyperaldosteronism. (MK) 

Hyperthyroidism. (MK) 

Hypercalcemia. (MK) 

Medication, alcohol, and illicit drug use. (MK) 

Coarctation of the aorta. (MK) 

Sleep apnea. (MK) 

6. The manifestations of target-organ disease due to hypertension. (MK) 

7. Classification of blood pressure (SBP and DBP for all age 18 or older). (MK) 

8. Basic approaches to the pharmacological management of acute and chronic hypertension, 

including the physiologic basis and scientific evidence supporting these approaches, and 

causes for lack of responsiveness to therapy. (MK) 

9. Prevention strategies for reducing hypertension (including lifestyle factors, such as dietary 

intake of sodium, weight, and exercise level), and explain the physiologic basis and/or 

154

scientific evidence supporting each strategy. (MK) 

10. Steps in management of patients with a hypertensive emergency. (MK) 

11. Factors that contribute to non-adherence with antihypertensive medications. (MK) 

B. SKILLS: Students should demonstrate specific skills including: 



Duration and levels of elevated blood pressure. (PC, CS) 

History of symptoms of cardiovascular, cerebrovascular, peripheral vascular or renal 

disease; diabetes; dyslipidemia; or gout. (PC, CS) 

History of symptoms suggesting secondary hypertension. (PC, CS) 

History of weight gain, leisure-time physical activities, and smoking or other tobacco use. 

(PC, CS) 

Family history of high blood pressure, premature CHD, stroke, CVD, diabetes mellitus and 

dyslipidemia. (PC, CS) 

Psychosocial and environmental factors that may elevate blood pressure (family situation, 

employment status, working conditions, education level). (PC, CS) 

Dietary assessment, including sodium intake and intake of saturated fat and cholesterol. 

(PC, CS) 

Results and side effects of previous antihypertensive therapy. (PC, CS) 

Use of commonly prescribed, over-the -counter, and illicit medications that may raise blood 

pressure or interfere with the effectiveness of antihypertensive medications. (PC, CS) 

Alcohol intake. (PC, CS) 



Blood pressure measurements to detect and confirm the presence of high blood pressure. 

(PC) 

Examination of the fundus for arteriolar narrowing, arteriovenous nicking, hemorrhages, 

exudates, or papilledema. (PC) 

Neck for carotid bruits, distended veins, or an enlarged thyroid gland. ((PC) 

Heart for increased rate, increased size, precordial heave, clicks, murmurs, arrhythmias, 

and third (S3) and fourth (S4) sounds. (PC) 

Abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation. (PC) 

Extremities for diminished, delayed, or absent peripheral arterial pulsations, bruits, and 

edema. (PC) 

Peripheral pulses specifically femoral arterial pulses. (PC) 

Body habitus, looking for changes associated with secondary hypertension. (PC) 

Peripheral and central nervous system for ischemic changes. (PC) 


diagnosis recognizing specific history, physical exam, and laboratory findings that suggest a 

specific etiology of hypertension. (PC, MK) 

4. Laboratory interpretation: Students should be able to recommend and interpret 

diagnostic and laboratory tests, both prior to and after initiating treatment based on the 

differential diagnosis, including consideration of test cost and performance characteristics as 

well as patient preferences. Laboratory and diagnostic tests should include, when appropriate: 

UA. (PC, MK) 

CBC. (PC, MK) 

Blood glucose (fasting if possible). (PC, MK) 

155

Electrolytes, BUN/Cr. (PC, MK) 

Uric acid. (PC, MK) 


ECG. (PC, MK) 


Communicate the diagnosis, treatment plan and prognosis of the disease to the patient and 

his or her family, taking into account the patient’s knowledge of hypertension and his or her 

preferences regarding treatment options. (PC, CS) 


Educate patients about hypertension risk factors, taking into account: 

o Demographics. (PC, CS) 

o Concomitant diseases and therapies. (PC, CS) 

o Quality of life. (PC, CS) 

o Physiologic and biochemical measurements. (PC, CS) 

o Economic considerations. (PC, CS) 

6. Basic and advanced procedural skills: Students should be able to perform: 

UA (dipstick and microscopic). (PC) 

12-lead ECG. (PC) 



Treating acute and chronic hypertension. (PC, MK) 

Treating primary (essential) hypertension versus secondary hypertension. (PC, MK) 


Prescribing preventative strategies to diminish hypertension, including: 

o Weight reduction. (PC, MK) 

o Moderation of alcohol intake. (PC, MK) 

o Regular physical activity. (PC, MK) 

o Reduction of sodium intake. (PC, MK) 

o Increase in potassium intake. (PC, MK) 

o Smoking cessation. (PC, MK) 


issues related to hypertension. (PC, PLI) 



1. Appreciate the importance of patient preferences and adherence with management plans for 

those with hypertension. (P) 

2. Recognize the responsibility of the physician with regard to non-adherence. (P) 

3. Respond appropriately to patients who are non-adherent to treatment for hypertension. (CS, P) 

4. Appreciate how preventative strategies may diminish need for medications. (P) 

5. Appreciate the importance of side effects of medications and their impact on quality of life and 

adherence (including those side effects to which the geriatric population may be more prone) 

and demonstrate a commitment to limiting the whenever possible. (P) 


considerations in the selection of diagnostic and therapeutic interventions for hypertension. 

(PLI, P) 

7. Demonstrate ongoing commitment to self-directed learning regarding hypertension. (PLI, P) 

8. Appreciate the impact hypertension has on a patient’s quality of life, wellbeing, ability to work, 

156



professions in the treatment of hypertension. (P, SBP) 


Chobanian, AV, Bakris, GL, Black, HR, et al. The seventh report of the joint national 

committee on prevention, detection, evaluation, and treatment of high blood pressure: 

the JNC 7 report. JAMA. 2003; 289:2560-72. 

www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm 

Major cardiovascular events in hypertensive patients randomized to doxazosin vs 

chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent 

heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. 

2000;283:1967-75. 

ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The 

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major 

outcomes in high-risk hypertensive patients randomized to angiotensin-converting 

enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid- 

Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97. 

Davis BR, Furberg CD, Wright JT Jr, Cutler JA, Whelton P. ALLHAT Collaborative 

Research Group. ALLHAT: setting the record straight. Ann Intern Med. 2004;141:39- 

46. 

Eisenberg MJ, Brox A, Bestawros AN. Calcium channel blockers: an update. Am J 

Med. 2004;116:35-43. 

Wing LM, Reid CM, Ryan P, et al. Second Australian National Blood Pressure Study 

Group. A comparison of outcomes with angiotensin-converting--enzyme inhibitors and 

diuretics for hypertension in the elderly. N Engl J Med. 2003;348:583-92. 

Agodoa LY, Appel L, Bakris GL, et al. African American Study of Kidney Disease and 

Hypertension (AASK) Study Group. Effect of ramipril vs amlodipine on renal outcomes 

in hypertensive nephrosclerosis: a randomized controlled trial. JAMA. 2001;285:2719- 

28. 

Brenner BM, Cooper ME, de Zeeuw D, et al. RENAAL Study Investigators. Effects of 

losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and 

nephropathy. N Engl J Med. 2001;345:861-9. 

Lewis EJ, Hunsicker LG, Clarke WR, et al. Collaborative Study Group. Renoprotective 

effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due 

to type 2 diabetes. N Engl J Med. 2001;345:851-60. 

Tuomilehto J, Rastenyte D, Birkenhager WH, et al. Effects of calcium-channel blockade 

in older patients with diabetes and systolic hypertension. Systolic Hypertension in 

Europe Trial Investigators. N Engl J Med. 1999;340:677-84. 

Anonymous. Tight blood pressure control and risk of macrovascular and microvascular 

complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. 

BMJ. 1998;317:703-13. 

Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensinconverting-enzyme 

inhibitor, ramipril, on cardiovascular events in high-risk patients. The 

Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 

2000;342:145-53. 

Dahlof B, Devereux RB, Kjeldsen SE, et al. LIFE Study Group. Cardiovascular 

morbidity and mortality in the Losartan Intervention For Endpoint reduction in 

hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:995- 

157

1003. 

158

TRAINING PROBLEM #25: LIVER DISEASE 

RATIONALE: 

The causes of hepatobiliary disease are many and can be quite overwhelming to the internal 

medicine clerk. A thorough understanding of a systematic approach to hyperbilirubinemia/jaundice is 

by far preferable to random knowledge of highly specific etiologies. The liver responds pathologically 

to injury in characteristic ways and knowledge of these patterns can also be very useful in differential 

diagnosis. Several etiologies of liver disease such as acute/chronic viral hepatitis and alcoholinduced 

liver disease are sufficiently common as to require specific attention. In addition, many liver 

diseases can result in cirrhosis and its complications and, therefore, understanding this end-stage 

development is important. 





Anatomy, physiology, and pathophysiology of the hepatobiliary system. 



1. The biochemical/physiologic/mechanistic approach to hyperbilirubinemia, including: 

Increased production. (MK) 

Decreased hepatocyte uptake. (MK) 

Decreased conjugation. (MK) 

Decreased excretion from the hepatocyte. (MK) 

Decreased small duct transport (intrahepatic cholestasis). (MK) 

Decreased large duct transport (extrahepatic cholestasis, obstructive jaundice). (MK) 

2. The biochemistry and common causes of unconjugated and conjugated hyperbilirubinemia. 

(MK) 

3. The use of serum markers of liver injury (e.g. AST, ALT, GGT, Alk Phos) and function (e.g. 

bilirubin, ALB, PT/INR) in the diagnostic evaluation of hepatobiliary disease. (MK) 

4. The clinical significance of asymptomatic, isolated elevation of AST, ALT, GGT, and/or Alk 

Phos. (MK) 

5. The common pathologic patterns of liver disease and their common causes, including: 

Steatosis (fatty liver). (MK) 

Hepatitis. (MK) 

Cirrhosis. (MK) 

Infiltrative. (MK) 

Intrahepatic cholestasis. (MK) 

Extrahepatic cholestasis (obstructive jaundice). (MK) 

6. The epidemiology, symptoms, signs, typical clinical course, and prevention of viral hepatitis. 

(MK) 

7. The distinctions between acute and chronic hepatitis. (MK) 

8. The indications for and efficacy of hepatitis A and B vaccinations. (MK) 

9. The common causes and clinical significance of hepatic steatosis and steatohepatis. (MK) 

159

10. The epidemiology, symptoms, signs, and typical clinical course of autoimmune liver diseases 

such as autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis. 

(MK) 

11. The epidemiology, symptoms, signs, and typical clinical course of cirrhosis. (MK) 

12. The pathophysiologic manifestations, symptoms, signs, and complications of alcohol-induced 

liver disease. (MK) 

13. The symptoms, signs, and complications of portal hypertension. (MK) 

14. The pathophysiology and common causes of ascites. (MK) 

15. The pathophysiologic manifestations, symptoms, and signs of spontaneous bacterial 

peritonitis. (MK) 

16. The basic pathophysiology, symptoms, signs, typical clinical course, and precipitants of 

hepatic encephalopathy. (MK) 

17. The basic pathophysiology, symptoms, signs, and typical clinical course of the hepatorenal 

syndrome. (MK) 

18. The analysis of ascitic fluid and its use in the diagnostic evaluation of liver disease. (MK) 

19. Common causes of drug-induced liver injury. (MK) 

20. Genetic considerations in liver disease (i.e. hemochromatosis, Wilson’s disease, alpha-1 

antitrypsin deficiency, Gilbert’s syndrome). (MK) 

21. The epidemiology, pathophysiology, symptoms, signs, and typical clinical course of 

cholelithiasis and cholecystitis. (MK) 

22. The clinical syndrome of “ascending cholangitis” including its common causes and typical 

clinical course. (MK) 

23. The indications for and risks of paracentesis and liver biopsy. (MK) 

24. The indications for and utility of hepatobiliary imaging studies, including: 

Ultrasound. (MK) 

Nuclear medicine studies. (MK) 

CT. (MK) 

MRI. (MK) 

Magnetic resonance cholangiopancreatography (MRCP). (MK) 

Endoscopic retrograde cholangiopancreatography (ERCP). (MK) 




including: 

Jaundice, discolored urine, pruritis, light-colored stool, unintentional weight loss, fever, 

nausea, emesis, diarrhea, altered mental status, abdominal pain, increased abdominal 

girth, edema, rectal bleeding, hematemesis. (PC, CS) 

DM. (PC, CS) 


Prescription, over-the-counter, and illicit drug use. (PC, CS) 

Transfusions and other sources of potential blood-born pathogen exposure. (PC, CS) 

Consumption of uncooked shellfish and other food items potentially contaminated with fecal 

matter. (PC, CS) 

Sexual history. (PC, CS) 

Vaccination history. (PC, CS) 

Family history of liver diseases. (PC, CS) 


160


Jaundice. (PC) 

Complete abdominal examination including findings consistent with ascites (e.g. bulging 

flanks, shifting dullness, fluid wave). (PC) 

Findings compatible with chronic alcohol use and portal hypertension (e.g. palmar 

erythema, spider angiomas, gynecomastia, testicular atrophy, Dupuytren’s contracture, 

muscle wasting, splenomegaly, ascites, edema, caput medusa, hemorrhoids). (PC) 

Findings compatible with hepatic (portosystemic) encephalopathy (e.g. disturbances of 

consciousness and behavior, fluctuating neurologic signs, asterixis). (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology of liver 

disease. (PC, MK) 






CBC. (PC, MK) 

Electrolytes, BUN/Cr, GLC. (PC, MK) 

ALB, TP, total bilirubin, direct bilirubin, PT/INR, AST, ALT, Alk Phos. (PC, MK) 

Hepatitis serology. (PC, MK) 

Ascitic fluid ALB, amylase, cell counts, staining, cultures, and the 

serum-ascites albumin gradient (SAAG). (PC, MK) 



Ultrasound. (PC, MK) 

Nuclear medicine studies. (PC, MK) 

CT. (PC, MK) 

MRI. (PC, MK) 

Magnetic resonance cholangiopancreatography (MRCP). (PC, MK) 

Endoscopic retrograde cholangiopancreatography (ERCP). (PC, MK) 






Discuss the avoidance of known hepatotoxins. (PC, CS) 

Counsel patients regarding alcohol abstinence. (PC, CS) 

Discuss the importance of hepatitis A and B vaccinations for nonimmune patients. (PC, CS) 


Assist in performing a paracentesis after explaining the procedure to the patient. (PC) 



The diagnostic evaluation of asymptomatic, isolated elevation of the transaminases and/or 

Alk Phos. (PC, MK) 

The diagnostic evaluation of patients with jaundice and unconjugated or conjugated 

hyperbilirubinemia. (PC, MK) 

The basic management of steatosis, hepatitis, cirrhosis, intra- and extra hepatic 

cholestasis, acute cholecystitis, ascites, portal hypertension, spontaneous bacterial 

161

peritonitis, and hepatic encephalopathy. (PC, MK) 

Determining when to obtain consultation from a gastroenterologist, hepatologist, or biliary 

surgeon. (PC, SBP) 



issues related to liver disease. (PC, PLI) 




considerations in the selection of diagnostic and therapeutic interventions for liver disease. (PLI, P) 


and therapeutic options for liver disease. (P) 

3. Respond appropriately to patients who are nonadherent to treatment for liver disease. (CS, P) 

4. Demonstrate ongoing commitment to self-directed learning regarding liver disease. (PLI, P) 

5. Appreciate the impact liver disease has on a patient’s quality of life, wellbeing, ability to work, 



healthcare professionals in the diagnosis and treatment of liver disease. (P, SBP) 

7. Discuss the public health role physicians play in the prevention of viral hepatitis. (P, SBP) 

8. Appreciate the difficulties patient face with alcohol abstinence. (P) 


Viral Hepatitis 


Center for Disease Control and Prevention 


www.cdc.gov/ncidod/diseases/hepatits/index.htm 

Practice Guidelines 

American Association for the Study of Liver Diseases 

www.aasld.org 

National Institute on Alcohol Abuse and Alcoholism 



www.niaaa.nih.gov 

Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in asymptomatic 

patients. N Engl J Med. 2000;342:1266-71. 

Angulo P. Nonalcoholic fatty liver disease. N Engl J Med. 2002;346:1221-31. 

Trowbridge RL, Rutkowski NK, Shojania. Does this patient have acute cholecystitis? 

JAMA. 2003;289:80-6. 

Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002;325:639-43. 

Krige JE, Bechingham IJ. ABC of diseases of liver, pancreas, and biliary system. 

Portal hypertension-1: varices. 

Krige JE, Bechingham IJ. ABC of diseases of liver, pancreas, and biliary system. 

Portal hypertension-2. Ascites, encephalopathy, and other conditions. BMJ. 

2001;322:416-8. 

162

TRAINING PROBLEM #26: MAJOR DEPRESSION 

RATIONALE: 

Major depression is a very common problem in adults, resulting in significant morbidity and mortality. 

Most often the primary care provider is the first health care professional to see a depressed patient. 

Frequently, the initial presentation is associated with somatic complaints that bring the patient to the 

physician. Major depression is also a relatively common accompaniment to serious medical 

conditions. There is significant evidence that primary care physicians commonly fail to diagnose 

major depression. With relatively recent improvements in available treatment, it is even more 

important for internists to screen for major depression and to know the common presenting 

symptoms. The internist should also be familiar with available therapeutic options and be prepared to 

treat selected patients, including those who decline consultation with a mental health professional. 





Neurochemistry of major depression. 

Pharmacology of the major classes of antidepressants. 

Basic understanding of the efficacy of psychotherapy, antidepressants, and electroconvulsive 

therapy. 



1. The epidemiology of major depression in the general population and the impact of major illness 

on the prevalence of major depression (e.g. stroke, heart disease, DM, cancer, Parkinson’s 

disease, HIV/AIDS). (MK) 

2. The impact of major depression on the outcome of medical illness. (MK) 

3. The American Psychiatric Associations’ Diagnostic and Statistical Manual 4 th edition (DSM-IV) 

diagnostic criteria for major depression. (MK) 

4. Common psychological symptoms and signs of major depression (e.g. low mood/affect, 

anxiety, irritability/anger, disinterest, anhedonia, decreased libido, guilt, poor self-esteem, poor 

concentration, rumination, helplessness, hopelessness, thoughts of death and suicide, somatic 

complaints). (MK) 

5. Common neurovegetative symptoms and signs of major depression (e.g. appetite disturbance, 

decreased energy, psychomotor retardation or agitation, sleep disturbance). (MK) 

6. Common somatic complaints that accompany depressive disorders and the potential for the 

occurrence of these symptoms without obvious psychological symptoms (e.g. fatigue, 

weakness, myalgias, arthralgias, headache, nausea, dyspnea, palpitations, chest 

pain/discomfort, lightheadedness/dizziness, bowel movement alterations). (MK) 

7. The distinguishing features of major depression with psychotic features, bipolar disorder, 

dementia, and delirium. (MK) 

8. The differential diagnosis of major depression, including: 

Other psychiatric disorders. (MK) 

Drug-induced (e.g. corticosteroids, cimetidine, metoclopramide, clonidine, etc.). (MK) 

163

Drug withdrawal (e.g. amphetamine, cocaine). (MK) 

Infection (e.g. tertiary syphilis). (MK) 

Endocrine/metabolic (e.g. hypo/hyperthyroidism, Cushing’s, Addison’s). (MK) 

Collagen vascular diseases (e.g. lupus, fibromyalgia). (MK) 

Neurologic (e.g. stoke, multiple sclerosis, Parkinson’s disease, head trauma, complex 

partial seizures). (MK) 

Nutritional (e.g. B12, folate, niacin, thiamine deficiencies). (MK) 

Neoplastic (e.g. pancreatic cancer, disseminated carcinomatosis). (MK) 

9. US Preventive Services Task Force (USPSTF) depression screening recommendations. (MK) 

10. The risks of untreated major depression. (MK) 

11. Assessment of the risk of suicide. (MK) 

12. The demographics and risk factors for completed suicide. (MK) 

13. The potential link between major depression and substance abuse. (MK) 

14. The potential role of genetics in depression.(MK) 

15. Indications and efficacy of the basic therapeutic options for major depression, including: 

Psychotherapy (cognitive behavioral therapy or interpersonal psychotherapy). (MK) 

Pharmacotherapy. (MK) 

Electroconvulsive therapy. (MK) 

16. The side effects of the major classes of antidepressants and common interaction with other 

medications. (MK) 



medical history, that differentiates among etiologies of disease including: 

Eliciting the symptoms of major depression. (PC, CS) 

Determining the presence or absence of underlying dementia, anxiety disorders, adverse 

drug effects, and grief in any patient suspected of having major depression. (PC, CS) 

Obtaining a complete drug history (including illicit drugs). (PC, CS) 

Identifying chronic diseases that are associated with increased risk of major depression. 

(PC, CS) 



A complete neurologic examination. (PC) 

A complete mental status exam. (PC) 



major depression (psychiatric and nonpsychiatric). (PC, MK) 






Blood and urine drug screening. (PC, MK) 

Thyroid function tests. (PC, MK) 

Serum RPR and VDRL. (PC, MK) 

B12, folate, and thiamine levels. (PC, MK) 



164








Demonstrate effective listening skills and empathy. (PC, CS) 

Advise the patient of the delay in therapeutic benefit from antidepressant medications. (PC, 

CS) 



An appreciation of the fact that major depression is not generally a “diagnosis of exclusion” 

and that ruling out all other possible medical causes is typically not necessary. (PC, MK) 

Making an accurate diagnosis of major depression. (PC, MK) 

Assessing for the risk of suicide. (PC, MK) 

Recommending psychotherapy (cognitive behavioral therapy or interpersonal 

psychotherapy). (PC, MK) 

Selecting appropriate initial pharmacologic therapy considering efficacy, side effects, and 

potential drug-drug interactions. (PC, MK, SBP) 

Identifying barriers to major depression treatment. (PC, SBP) 

Anticipating potential resistance to seeing a psychiatrist and antidepressant treatment. (PC) 

Planning appropriate follow-up. (PC, MK) 

Recognizing success or failure of initial treatment and making appropriate adjustments. 

(PC, MK) 

Determining when to obtain consultation from a psychiatrist, psychologist, or other mental 

health professional. (PC, SBP) 

Using a cost-effective approach to treatment. (PC, SBP) 


issues related to major depression. (PC, PLI) 

Incorporating patient needs and preferences. (PC) 


1. Recognize major depression as an important and potentially life-threatening disease. (P) 

2. Appreciate the social stigma of psychiatric diagnoses and the ways non-psychiatric physicians 

may inadvertently contribute to this. (P) 

3. Appreciated the reluctance of some patients to see a psychiatrist. (P) 


considerations in the selection of diagnostic and therapeutic interventions for major depression. (PLI, 

P) 


and therapeutic options for major depression. (P) 

6. Respond appropriately to patients who are nonadherent to treatment for major depression. 

(CS, P) 

7. Demonstrate ongoing commitment to self-directed learning regarding major depression. (PLI, 

P) 

8. Appreciate the impact major depression has on a patient’s quality of life, wellbeing, ability to 


165

9. Recognize the importance of and demonstrate a commitment to the utilization of other health 

care professionals in the diagnosis and treatment of major depression. (P, SBP) 


Depression 

National Institute of Mental Health 



www.nimh.nih.gov/publicat//defresssion.cfm 

Practice Guidelines 

American Psychiatric Association 

www.psych.org/psych_pract/treatg/pg/prac_guide.cfm 

The National Association on Mental Illness 

www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPa 

ge/TaggedPageDisplay.cfm&TPLID=54&ContentID=26414 

Mann JJ. The medical management of depression. N Engl J Med. 2005;353:1819-34. 

166

TRAINING PROBLEM #27: NOSOCOMIAL INFECTIONS 

RATIONALE: 

Nosocomial infections have been occurring since the inception of the hospital. Despite many 

advances the incidence is still roughly five percent of all acute care hospitalizations or about two 

million cases a year. Nosocomial infections are estimated to approximately double the morbidity and 

mortality rates of any person admitted to the hospital. Directly attributable deaths can total up to 

88,000 per year with the expenditure of many millions of excess health care dollars. Preventing 

nosocomial infections is the responsibility of every heath care worker, including physicians, house 

officers, medical students, nurses, technicians, administrators, etc. Also considered here are 

occupational exposures for which health care workers are at risk. 





Basic training in body substance isolation procedures. 

Microbiology and pathophysiology of the common nosocomial organisms, including 

Staphylococcus aureus (methicillin sensitive and resistant), Staphylococcus epidermidis, 

Enterococcus species (vancomycin sensitive and resistant), Pseudomonas aeruginosa and 

other nosocomial gram-negative bacilli, Clostridium difficile, and Candida species. 

The pharmacology of antimicrobial agents. 



1. The epidemiology and significance of nosocomial infections in the United States. (MK) 

2. The general clinical risk factors for nosocomial infection. including: 

Immunocompromise. (MK) 

Immunosuppressive drugs. (MK) 

Extremes of age. (MK) 

Compromise of the skin and mucosal surfaces secondary to: 

o Drugs. (MK) 

o Irradiation. (MK) 

o Trauma. (MK) 

o Invasive diagnostic and therapeutic procedures. (MK) 

o Invasive indwelling devises (e.g. intravenous catheter, bladder catheter, endotracheal 

tube, etc.). (MK) 

3. The major routes of nosocomial infection transmission, including: 

Contact. (MK) 

Droplet. (MK) 

Airborne. (MK) 

Common vehicle. (MK) 

4. The epidemiology, pathophysiology, microbiology, symptoms, signs, typical clinical course, 

and preventive strategies for the most common nosocomial infections, including: 

Urinary tract infection. (MK) 

167


Surgical site infection. (MK) 

Intravascular devised-related bloodstream infections. (MK) 

Skin infections. (MK) 

Health care associated diarrhea. (MK) 

5. Empiric antibiotic therapy for the most common nosocomial infections. (MK) 

6. The epidemiology, pathophysiology, microbiology, symptoms, signs, typical clinical course, 

and preventive strategies for colonization or infection with the following organisms: 

Vancomycin-resistant enterococci. (MK) 

Clostridium difficile. (MK) 

Methicillin-resistant Staphylococcus aureus. (MRSA) (MK) 

Multidrug-resistant Gram-negative bacteria. (MK) 

7. The crucial importance of judicious antibiotic use. (MK) 

8. The effect of widespread use of broad spectrum anti-microbial agents on endogenous body 

flora and the hospital microbial flora. (MK) 

9. The types of isolation procedures and their indications: 

Standard. (MK) 

Airborne. (MK) 

Contact. (MK) 

Droplet. (MK) 

10. The Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene. (MK) 

11. Preventive strategies for needlestick and sharps injuries intended to reduce the transmission of 

bloodborne pathogens (hepatitis B, hepatitis C, and HIV). (MK) 

12. Local hospital post-exposure (i.e. after an eye/mucous membrane splash, needlestick or other 

sharps injury) protocols for prompt reporting, evaluation, counseling, treatment, and follow-up. 

(MK, SBP) 

13. The indications, efficacy, and side effects of post-exposure prophylaxis for hepatitis B and 

HIV/AIDS. (MK) 

14. negative-pressure ventilation isolation for known or suspected tuberculosis patients (MK) 

15. National Institute for Occupational Safety and Health (NIOSH) approved personal respiratory 

protective equipment (i.e. N95 respirator) use for the prevention of transmission of 

Mycobacterium tuberculosis to health care workers. (MK) 



medical history, that differentiates among etiologies of disease in the organ systems 

likely to be involved with nosocomial infection. (PC, CS) 

4. Physical exam skills: Students should be able to perform a physical examination of skin, 

vascular access sites, lungs, abdomen, wounds, and catheter and drain sites and recognize signs 

of local or systemic infection (PC) 


of the likely sites and organisms involved, recognizing specific history and physical exam 

findings that suggest a specific etiology. (PC, MK) 



based o the differential diagnosis, including consideration of test cost and performance 

168



Urinalysis and culture and sensitivities. (PC, MK) 

Sputum Gram stain and culture and sensitivities. (PC, MK) 


Wound cultures and sensitivities. (PC, MK) 

Clostridium difficile toxin assay. (PC, MK) 

Hepatitis serologies. (PC, MK) 

HIV ELISA and western blot. (PC, MK) 

Sputum AFB staining and culture. (PC, MK) 






Explain the necessity for isolation procedures. (PC, CS) 

Counsel patients about the need for judicious antibiotic usage and the potential patientspecific 

and public health risks of not doing so. (PC, CS) 




Demonstrate proper sterile technique for invasive procedures. (PC) 



Assessing a hospitalized patient who develops a new fever 48 or more hours after 

admission. (PC, MK) 

Developing a plan for the evaluation and treatment of hospital acquired infection. (PC, MK) 

Demonstrating appropriate choice of antimicrobial drugs which considers mechanisms of 

action, spectrum of activity, pharmacokinetics, drug interactions, and adverse reactions. 

(PC, MK) 

Recognizing when indwelling intravascular and urinary collection devices should be 

removed. (PC, MK) 

Requesting appropriate isolation measures to protect other patients and health care 

workers. (PC, SBP) 

Determining when to obtain consultation from an infectious diseases specialist. (PC, SBP) 

Contacting hospital infection control experts when appropriate. (SBP) 



issues related to nosocomial infections. (PC, PLI) 

Incorporating patient needs and preferences. (PC) 


1. Serve as a role model to all other health care providers by strictly following all infection control 

measures including hand hygiene and all isolation procedures. (P, SBP) 

2. Appreciate the role physicians play in the inappropriate prescribing of antimicrobial agents and 

the public health ramifications. (P, SBP) 


considerations in the selection of diagnostic and therapeutic interventions for nosocomial infections. 

169

(PLI, P) 


and therapeutic options for nosocomial infections. (P) 

5. Demonstrate ongoing commitment to self-directed learning regarding nosocomial infections. 

(PLI, P) 

6. Appreciate the impact nosocomial infections have on a patient’s quality of life, well-being, 



care professionals in the diagnosis, treatment, and prevention of nosocomial infections. (P, SBP) 


Infection Control Guidelines 

Division of Healthcare Quality Promotion 




www.cdc.gov/ncidod/hip/default.htm 

Vancomycin-Resistant Enterococci Division of Healthcare 

Quality Promotion National Center for Infectious Diseases 



www.cdc.gov/ncidod/hip/ARESIST/vre.htm 

Pautanen SM, Simor AE. Clostridium difficile associated diarrhea in adults. Can Med 

Assoc J. 2004;171:51-8. 

www.cmaj.ca/cgi/reprint/171/1/51 

Healthcare-Associated MRSA Division of Healthcare Quality Promotion National Center 

for Infectious Diseases Centers for Disease Control and Prevention 


www.cdc.gov/ncidod/dhqp/ar_mrsa.html 

170

TRAINING PROBLEM #28: OBESITY 

RATIONALE: 

Obesity and overweight are recognized as ever growing epidemics in the United States. These 

conditions have been correlated with the development of medical conditions such as diabetes, 

hypertension, heart disease, and osteoarthritis. Mastery of the approach to patients who are not at 

an ideal body weight is important to general internists because they often deal with the sequelae of 

the comorbid illnesses. 





Psychology associated with addictive behavior. 

Anatomy, physiology, and pathophysiology of the gastrointestinal tract and digestion. 

Pharmacology of the available drugs used to treat obesity. 

Nutrition and caloric requirements. 



1. The etiology of obesity including excessive caloric intake, insufficient energy expenditure 

leading to low resting metabolic rate, genetic predisposition, environmental factors affecting weight 

gain, psychologic stressors, and lower socioeconomic status. (MK) 

2. The definition and classification of overweight and obese using BMI. (MK) 

3. The health implications that being overweight or obese may have on the patient. (MK) 

4. How daily caloric requirements are calculated and the caloric deficit required to achieve a five 

to 10 percent weight reduction in six to 12 months. (MK) 

5. The principles of behavior modification. (MK) 

6. How to develop an exercise program and assist the patient in setting goals for weight loss. 

(MK) 

7. Treatment options, including nonpharmacologic and pharmacologic treatment, behavioral 

therapy and surgical intervention. (MK) 



age-appropriate medical history, including: 

Reviewing the patient’s weight history from childhood. (PC, CS) 

Assessing the risk factors for obesity related conditions. (PC, CS) 

Assessing the patient’s motivation for losing weight. (PC, CS) 

Reviewing the patient’s past experience with losing weight and determining barriers 

encountered in prior attempts. (PC, CS) 

Reviewing the patient’s activity level and diet. (PC, CS) 

Obtaining an assessment of tobacco and drug use especially noting if the patient is in the 

171

process of stopping either. (PC, CS) 

Obtaining a family history focusing on weight related issues and comorbid illnesses 

associated with obesity. (PC, CS) 

Obtaining a focused review of systems including signs and symptoms of secondary causes 

of obesity such as Cushing’s syndrome, hypothyroidism, and hypogonadism. (PC, CS) 



Calculation of degree of obesity from the patient’s height and weight by calculating BMI. 

(PC) 

Noting the presence of abdominal obesity based on waist-to-hip circumference. (PC) 

Assessing the signs of vascular disease including hypertension, carotid bruits, abdominal 

aortic size, blood pressure and peripheral pulses. (PC) 

Assessing for signs of endocrine abnormalities, including: striae, peripheral neuropathy, 

depressed tendon reflexes, bruising, and signs of dyslipidemia (e.g. xanthomas and 

xanthalasma). (PC) 



primary and secondary obesity. (MK, PC) 






Serum GLC. (PC, MK) 

TSH. (PC, MK) 

Lipid profile. (PC, MK) 

HbA1c. (PC, MK) 

BUN/Cr. (PC, MK) 

Urine microalbumin. (PC, MK) 

ECG. (PC, MK) 

24-hour urinary cortisol (PC, MK) 



CS) 


Adapt to the patient’s life-style and preferences, with emphasis on the patient’s role in 

treatment and maximizing compliance. (PC, CS) 

Assist the patient in understanding that attainment of ideal body weight may not necessarily 

be a realistic goal and that health benefits may be achieved with losses of five to 10 

percent body weight. (PC, CS) 



Determining when to obtain consultation from an endocrinologist, dietician, or obesity 

management specialist. (PC, SBP) 

Developing reasonable weight loss goals with the patient. (PC, MK) 

Developing a dietary plan. (PC, MK) 

Developing a prescription for physical activity. (PC, MK) 

Identifying indications for pharmacotherapy. (PC, MK) 

Identifying indications for bariatric surgery. (PC, MK) 

172


issues related to obesity. (PC, PLI) 

Incorporating patient preferences in the treatment plan. (PC) 



considerations in the selection diagnostic and therapeutic interventions for obesity. (PLI, P) 

2. Respond appropriately to patients who are nonadherent to treatment for obesity. 

(CS, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding obesity. (PLI, 

P) 

4. Appreciate the impact obesity has on a patient’s quality of life, well-being, ability to 

work, and family. (P) 


other healthcare professions in the treatment of obesity. (P, SBP) 


Overweight and Obesity 

National Center for Chronic Disease Prevention and Health Promotion Center for Disease 

Control and Prevention 


www.cdc.gov/nccdphp/dnpa/obesity 

Aim for a Healthy Weight National Heart, Lung, and Blood Institute Obesity Education 

Initiative National Institutes of Health 


www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm 

Screening for Obesity in Adults 



www.ahrq.gov/clinic/uspstf/uspsobes.htm 

Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss 

programs in the United States. Ann Intern Med. 2005;152-56-66. 

Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and 

meta-analysis. JAMA. 2004;292:1724-37. 

Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of obesity. Ann 

Intern Med. 2005;142:532-46. \ 

173

TRAINING PROBLEM #29: PNEUMONIA 

RATIONALE: 

Pneumonia continues to be a major public health issue, a leading reason for hospitalization, and 

a significant cause of mortality. Not only that, it is an important complication of admission for 

other causes. Many different specialties encounter pneumonia in the course of practice, the 

internist most particularly. 





Anatomy and physiology of the pulmonary system. 

Pathogenesis and pathophysiology of pneumonia. 

Microbiology of the common pneumonia pathogens. 

Pharmacology of antimicrobial agents. 



1. The epidemiology, pathophysiology, symptoms, signs, and typical clinical course of 

community-acquired, nosocomial, and aspiration pneumonia and pneumonia in the 

immunocompromised host. (MK) 

2. The conceptualization of “typical” and “atypical” pneumonia and its limitations. (MK) 

3. Common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in 

immunocompetent and immunocompromised hosts). (MK) 

4. Identify patients who are at risk for impaired immunity. (MK) 

5. Indications for hospitalization and ICU admission of patient with pneumonia. (MK) 

6. The radiographic findings of the various types of pneumonia. (MK) 

7. The antimicrobial treatments (e.g. antiviral, antibacterial, antimycobacterial, and antifungal) 

for community-acquired, nosocomial, and aspiration pneumonia, and pneumonia in the 

immunocompromised host. (MK) 

8. The implications of antimicrobial resistance. (MK) 

9. The pathogenesis, symptoms, and signs of the complications of acute bacterial pneumonia 

including: bacteremia, sepsis, parapneumonic effusion, empyema, meningitis, and 

metastatic microabscesses. (MK) 

10. The indications for and complications of chest tube placement. (MK) 

11. The indications for and efficacy of influenza and pneumococcal vaccinations. (MK) 

12. The indications and procedures for respiratory isolation. (MK) 


Accreditation of Healthcare Organizations (JCAHO) quality measures for communityacquired 

pneumonia treatment. (MK, PLI, SBP) 




174

The presence and quantification of fever, chills, sweats, cough, sputum, hemoptysis, 

dyspnea, and chest pain. (PC, CS) 

Historical features consistent with potential immunocompromise. (PC, CS) 

potential tuberculosis exposure (PC, CS) 




Identifying bronchial breath sounds, rales, rhonchi, and wheezes. (PC) 

Identifying signs of pulmonary consolidation. (PC) 

Identifying signs of pleural effusion. (PC) 

Identifying signs of the complications of pneumonia. (PC) 



etiology of pneumonia and other possible diagnoses, including: 

Common cold. (PC, MK) 

Acute bronchitis. (PC, MK) 

Influenza. (PC, MK) 

Acute exacerbation of COPD. (PC, MK) 

Asthma exacerbation. (PC, MK) 

CHF. (PC, MK) 

Pulmonary embolism. (PC, MK) 

Aspiration. (PC, MK) 






CBC. (PC, MK) 


ABG. (PC, MK) 

Pleural fluid chemistry, cell counts, staining, and culture. (PC, MK) 






Communicate the diagnosis, treatment plan, prognosis, and subsequent follow-up to the 

patient and his or her family. (PC, CS) 


Educate the patient about pneumococcal and influenza immunizations. (PC, CS) 

Educate the patient about the importance of smoking cessation. (PC, CS) 


Place and interpret a tuberculin skin test (PPD). (PC) 





175

Selecting an appropriate empiric antibiotic regimen for community-acquired, nosocomial, 

immunocompromised-host, and aspiration pneumonia, taking into account pertinent patient 

features. (PC, MK) 

Adjusting antimicrobial treatment according to the sputum staining and culture results. (PC, 

MK) 

Recognizing the complications of pneumonia. (PC, MK) 

Determining when to obtain consultation from a pulmonologist or infectious diseases 

specialist. (PC, SBP) 



issues related to pneumonia. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for the various types of 

pneumonia. (PLI, P) 


therapeutic options for pneumonia. (P) 

3. Demonstrate ongoing commitment to self-directed learning regarding pneumonia. (PLI, P) 

4. Appreciate the impact pneumonia has on a patient’s quality of life, well-being, ability to work, 



healthcare professionals in the treatment of pneumonia. (P, SBP) 

6. Appreciate the importance of antimicrobial resistance. (P) 

7. Appreciate the public health role of the physician when treating certain types of pneumonia 

(e.g. tuberculosis). (P) 

8. Appreciate the importance of and demonstrate a commitment to meeting national health care 

quality measures for the treatment of acute MI. (P, SBP, PLI) 


Improving Treatment Decisions for Patients with Community-Acquired Pneumonia Agency 

for Healthcare Research and Quality 


www.ahrq.gov/clinic/pneumonia/pneumonria.htm 

Ramsdell J, Narsavage GL, Fink JB. Management of community-acquired pneumonia 

in the home: an American College of Chest Physicians clinical position statement. 

Chest. 2005;127:1752-63. 

www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7325&nbr=4 348 

Influenza 



www.cdc.gov/flu/ 

Prevention of Pneumococcal Disease: Recommendations of the Advisory 

Committee on Immunization Practices (ACIP). MMWR 46(RR-08);1-24. Centers for 

Disease Control and Prevention 


176

www.cdc.gov/mmwr/PDF/RR/RR4608.pdf 

Prevention and Control of Influenza: Recommendations of the Advisory Committee 

on Immunization Practices (ACIP). MMWR 50(RR-04);1-46. Centers for Disease 

Control and Prevention 


www.cdc.gov/mmwr/PDF/RR/RR5004 

177

TRAINING PROBLEM #30: RHEUMATOLOGIC PROBLEMS 

RATIONALE: 

Rheumatologic diseases are an important part of the practice of internal medicine. This includes 

problems referring to specific joints as well as patients with systemic symptoms that are sometimes 

difficult to unify into a single diagnosis. 





Anatomy, physiology, and pathophysiology of the musculoskeletal system. 

Basic course work in immunology. 

Pharmacology of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), 

glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), drugs use in the treatment 

of gout. 

Basic bone radiograph interpretation. 



1. A systematic approach to joint pain based on an understanding of pathophysiology to classify 

potential causes. (MK) 

2. The effect of the time course of symptoms on the potential causes of joint pain (acute vs. 

subacute vs. chronic). (MK) 

3. The difference between and pathophysiology of arthralgia vs. arthritis and mechanical vs. 

inflammatory joint pain. (MK) 

4. The distinguishing features of intra-articular and periarticular complaints (joint pain vs. bursitis 

and tendonitis). (MK) 

5. 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). (MK) 

6. Indications for performing an arthrocentesis and the results of synovial fluid analysis. (MK) 

7. The pathophysiology and common signs and symptoms of: 

Osteoarthritis. (MK) 

Crystalline arthropathies. (MK) 

Septic arthritis. (MK) 

8. Indications for and effectiveness of intra-articular steroid injections. (MK) 

9. Treatment options for gout (e.g. colchicine, NSAIDs, steroids, uricosurics, xanthine oxidase 

inhibitors). (MK) 

10. The pathophysiology and common signs and symptoms of common periarticular disorders: 

Sprain/stain. (MK) 

Tendonitis. (MK) 

Bursitis. (MK) 

11. The basic pathophysiology of autoimmunity and autoimmune diseases. (MK) 

12. The basic role of genetics in autoimmune disorders. (MK) 

178

13. Typical clinical scenarios when systemic rheumatologic disorders should be considered: 

Diffuse aches and pains. (MK) 

Generalized weakness/fatigue. (MK) 

Myalgias with or without weakness. (MK) 

Arthritis with systemic signs (e.g. fever, weight loss). (MK) 

Arthritis with disorders of other systems (e.g. rash, cardiopulmonary symptoms, 

gastrointestinal symptoms, eye disease, renal disease, neurologic symptoms). (MK) 

14. The common signs and symptoms of and diagnostic approach to: 

Rheumatoid arthritis. (MK) 

Spondyloarthropathies (reactive arthritis/Reiter’s syndrome, ankylosing spondylitis, 

psoriatic arthritis). (MK) 

Systemic lupus erythematosus. (MK) 

Systemic sclerosis. (MK) 

Raynaud’s syndrome/phenomenon. (MK) 

Sjögren’s syndrome. (MK) 

Temporal arteritis and polymyalgia rheumatica. (MK) 

Other systemic vasculitides. (MK) 

Polymyositis and dermatomyositis. (MK) 

Fibromyalgia. (MK) 




Eliciting features of joint complaints: 

o Pain. (PC, CS) 

o Stiffness. (PC, CS) 

o Location. (PC, CS) 

o Mode of onset. (PC, CS) 

o Duration. (PC, CS) 

o Severity. (PC, CS) 

o Exacerbating and alleviating factors. (PC, CS) 

o Warmth, redness, and tenderness. (PC, CS) 

o Associated nonarticular symptoms. (PC, CS) 

Determining when in the course of acute arthritis it is necessary to obtain a sexual history. 

(PC, CS) 

Determining the impact of rheumatologic complaints on a patient's activities of daily living. 

(PC, CS) 



A systematic examination of all joints identifying the following abnormal findings: 

o Erythema, warmth, tenderness, and swelling. (PC) 

o Effusion. (PC) 

o Crepitus. (PC) 

o Altered range of motion. (PC) 

o Ulnar deviation. (PC) 

o Synovial thickening. (PC) 

o Joint alignment deformities (e.g. varus and valgus). (PC) 

o Podagra. (PC) 

179

Muscular bulk, strength, and tenderness. (PC) 

Examination of the skin identifying the following abnormal findings: 

o Rheumatoid and tophaceous nodules. (PC) 

o Alopecia. (PC) 

o Malar rash. (PC) 

o Sclerodactyly. (PC) 

o Telangiectasias. (PC) 

o Raynaud’s phenomenon. (PC) 

o Psoriasis. (PC) 

o Cutaneous manifestations of vasculitis (e.g. palpable purpura). (PC) 


recognizing specific history and physical exam findings that suggest a specific etiology: 

Osteoarthritis. (PC, MK) 

Crystalline arthropathies. (PC, MK) 

Septic arthritis. (PC, MK) 

Rheumatoid arthritis. (PC, MK) 

Spondyloarthropathies (reactive arthritis/Reiter’s syndrome, ankylosing spondylitis, 

psoriatic arthritis). (PC, MK) 

Systemic lupus erythematosus. (PC, MK) 

Systemic sclerosis. (PC, MK) 

Raynaud’s syndrome/phenomenon. (PC, MK) 

Sjörgren’s syndrome. (PC, MK) 

Temporal arteritis and polymyalgia rheumatica. (PC, MK) 

Other systemic vasculitides. (PC, MK) 

Polymyositis and dermatomyositis. (PC, MK) 

Fibromyalgia. (PC, MK) 

5. Laboratory interpretation: Students should be able to recommend when to order diagnostic and 

laboratory tests and be able to interpret them, both priorto and after initiating treatment based 

on the differential diagnosis, including consideration of test cost and performance 




Synovial fluid analysis (Gram stain, culture, crystal exam, cell count with differential, and 

glucose). (PC, MK) 

Uric acid. (PC, MK) 

ESR. (PC, MK) 

Rheumatoid factor (RF). (PC, MK) 

Antinuclear antibody test (ANA) and anti-DNA test. (PC, MK) 



Plain radiographs of the shoulder, elbow, wrist, hand, hip, knee, ankle, and foot. (PC, MK) 



CS) 

Elicit questions from the patient about the management plan. (PC, CS) 


Assist in the performance of an arthrocentesis and intra-articular corticosteroid 

injection. (PC) 


180


Selecting appropriate medications for the relief of joint pain. (PC, MK) 

Prescribing acute and preventative treatment for crystalline arthropathies. (PC, MK) 

Prescribing basic treatment options for septic arthritis. (PC, MK) 

Prescribing basic treatment options for systemic rheumatologic conditions. (PC, MK) 

Determining when to obtain consultation from a rheumatologist and orthopedic surgeon. 

(PC, SBP) 



issues related to rheumatologic problems. (PC, PLI) 




considerations in the selection diagnostic and therapeutic interventions for rheumatologic 

problems. (PLI, P) 


therapeutic options for rheumatologic problems. (P) 

3. Respond appropriately to patients who are nonadherent to treatment for rheumatologic 

problems. (CS, P) 

4. Demonstrate ongoing commitment to self-directed learning regarding rheumatologic problems. 

(PLI, P) 

5. Appreciate the impact rheumatologic problems have on a patient’s quality of life, well-being, 


6. Recognize the importance of and demonstrate a commitment to the utilization 

of other healthcare professions in the treatment of rheumatologic problems. (P, SBP) 


Evaluation of the patient – history and physical examination, laboratory assessment, 

arthrocentesis and synovial fluid analysis. In Schumacher HR, Klippel JH, Koopman 

WJ, eds. Primer on the Rheumatic Diseases. 12 th Ed. Atlanta, GA: Arthritis Foundation; 

2001. 

Management Guidelines 

American College of Rheumatology 

www.rheumatology.org/publications/guidelines/index.asp 

Arthritis Foundation 

www.arthritis.org 

National Institute of Arthritis and Musculoskeletal and Skin Diseases 



www.niams.nih.gov 

181

TRAINING PROBLEM #31: SMOKING CESSATION 

RATIONALE: 

Smoking is a major public health issue because it causes or aggravates many serious illnesses. 

Effective intervention strategies for chronic smokers have been developed using principals of 

behavioral counseling. These principals are applicable to other risky health behaviors. Health 

behavior risk assessment and intervention is now expected of physicians as part of the 

comprehensive care of adults. Selecting and performing an appropriate smoking cessation 

intervention is an important training problem for the third year medical student. 





Knowledge of the anatomy, physiology, and pathophysiology of the cardiopulmonary system. 

Knowledge of the pharmacology of addictive drugs. 

Knowledge of the risks of smoking, passive smoke, and smokeless tobacco. 

Appreciation of the reasons for or against discontinuing smoking. 



1. The pharmacologic effects of nicotine. (MK) 

2. Nicotine withdrawal symptoms. (MK) 

3. Intervention strategies physicians can use for those patients willing and not willing to quit. (MK) 

4. The stages of change, including: 

Precontemplation. (MK) 

Contemplation. (MK) 

Preparation. (MK) 

Action. (MK) 

Maintenance. (MK) 

5. The “five A’s” of smoking cessation: 

Ask. (MK) 

Advise. (MK) 

Assess. (MK) 

Assist. (MK) 

Arrange. (MK) 

6. The “five R’s” of smoking cessation: 

Relevance. (MK) 

Risks. (MK) 

Rewards. (MK) 

Roadblocks. (MK) 

Repetition. (MK) 

7. The common barriers preventing patients from undertaking smoking cessation. (MK) 

8. The principles of at least one theory of behavior modification. (MK) 

9. Common medical diseases associated with chronic smoking and the effects of stopping on 

182

future risk. (MK) 

10. The indications for nicotine replacement therapy, pharmacotherapy (i.e. bupropion) or both. 

(MK) 

11. The association between smoking cessation and weight gain. (MK) 

12. The fact that tobacco dependence is considered a chronic relapsing disorder. (MK) 


Accreditation of Healthcare Organizations (JCAHO) quality measures for smoking cessation 

advice (i.e. all smoking patients admitted with pneumonia, HF, or an acute MI are given 

smoking cessation advice or counseling during hospital stay). (MK, PLI, SBP) 



medical history, including: 

Ask the patient if he or she uses tobacco. (PC, CS) 

Determine the length and magnitude of tobacco use. (PC, CS) 

Ask if the patient is interested in stopping. 

Ask about the patient’s past experiences with smoking cessation. (PC, CS) 

Ask relevant questions regarding the symptoms of diseases associated with long-term 

smoking (e.g. CAD, COPD, PVD, CVA, lung cancer). (PC, CS) 



Identification of nicotine stains. (PC) 

Identification of lesions with malignant potential on the lips and in the oral cavity. (PC) 

Identification of chest findings consistent with chronic obstructive lung disease and lung 

cancer. (PC) 

Examination of the heart and vascular system. (PC) 






Complete blood count to detect erythrocytosis. (PC, MK) 

Lipid profile to aid in cardiovascular stratification. (PC, MK) 


1. Ask every patient if he or she uses tobacco. (PC, CS) 

2. Advise every patient who smokes to stop in a nonjudgmental manner. (PC, CS) 

3. Assess the patient’s willingness to make attempt to quit. (PC, CS) 

4. Assist those who are willing to make a quit attempt through counseling. (PC, CS) 

5. Respond positively and non-judgmentally to the patient’s excuses or concerns about 

cessation. (PC, CS) 

6. Get the patient to commit to a specific action plan that can lead to complete 

cessation. (PC, CS) 

7. For those unwilling to quit, use of “5 R’s” to motivate the patient: 

o Relevance. (PC, CS) 

o Risks. (PC, CS) 

o Rewards. (PC, CS) 

183

o Roadblocks. (PC, CS) 

o Repetition. (PC, CS) 


treatment plan for patient, including: 

Designing an intervention that matches the stage of behavior change demonstrated by the 

patient. (PC, CS) 

Explaining how to use nicotine patch, nasal spray or inhaler, and/or bupropion therapy. 

(PC, CS) 

Negotiating a follow-up plan with the patient. (PC, CS) 

Encouraging the patient to increase physical activity to lessen weight gain, if medically 

appropriate. (PC, CS) 


issues/resources related to aiding smoking cessation. (PC, PLI) 


C. ATTITUDES AND PROFESSIONAL BEHAVIORS: Student should be able to: 

1. Demonstrate a commitment to meeting national quality standards for smoking cessation. (P, 

PLI, SBP) 

2. Maintain a non-judgmental attitude at all times regarding smoking cessation. (P) 

3. Demonstrate a commitment to deliver a non-judgmental "stop smoking" message to every 

patient who smokes. (P) 

4. Promote problem-solving by the patient. (P) 


considerations in the selection of diagnostic and therapeutic interventions for smoking 

cessation. (PLI, P) 

6. Respond appropriately to patients who are non-adherent to treatment for smoking cessation. 

(P) 

7. Demonstrate ongoing commitment to self-directed learning regarding smoking cessation. (PLI, 

P) 

8. Appreciate the impact smoking cessation has on a patient’s quality of life, well-being, ability to 

work, and the famRecognize the importance and demonstrate a commitment to the utilization 

of other healthcare professions in the treatment of smoking cessation. (P, SBP) 

D. RESOURCES: 

Public Health Service 

Department of Health and Human Services 

Tobacco Cessation Guideline 

www.surgeongeneral.gov/tobacco/default.htm 

Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for 

smoking cessation. Cochrane Database of Syst Rev. 2004;(3):CD000146. 

Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294:482-7. 

Talwar A, Jain M, Vijayan VK. Pharmacotherapy of tobacco dependence. Med Clin 

North Am. 2004;88:1517-34. 

184

TRAINING PROBLEM #32: SUBSTANCE ABUSE 

RATIONALE: 

Substance abuse is a prevalent problem that intersects with patient care on a variety of different 

levels and in patients from every socio-economic status. Being able to recognize it, counsel 

patients appropriately, and devise an appropriate treatment plan is integral to the practice of 

internal medicine. 


Prior knowledge, skills, and attitudes acquired during the pre-clerkship experiences should 

include: 



Knowledge of drug and alcohol metabolism and physiology. 



1. Presenting signs and symptoms of abuse of the following substances: 

Alcohol. (MK) 

Opioids. (MK) 

Cocaine. (MK) 

Amphetamines.(MK) 

Hallucinogens. (MK) 

Barbiturates. (MK) 

Marijuana. (MK) 

Anabolic steroids. (MK) 

Benzodiazepines. (MK) 

2. Signs, symptoms, risk factors for, and major causes of morbidity and mortality secondary to 

alcohol and drug abuse, intoxication, overdose, and withdrawal. (MK) 

3, Diagnostic criteria for substance abuse, dependency and addiction. (MK) 

4. Questions in the CAGE questionnaire: 

Cut down. (MK) 

Annoyed/angry. (MK) 

Guilty. (MK) 

Eye opener. (MK) 

5. Health benefits of substance abuse cessation. (MK) 

6. The potential role of genetics in substance abuse vulnerability. (MK) 




including: 

Social history that is elicited in a nonjudgmental, supportive manner, using appropriate 

questioning (e.g. CAGE questions, etc.). (PC, CS) 

185

Use of injection drugs and shared needles. (PC, CS) 

Relevant medication history. (PC, CS) 

Immune status. (PC, CS) 

Family history of substance abuse. (PC, CS) 

Lifestyle factors that will influence patient’s access to illicit substances and interfere with 

ability to enable effective treatment. (PC, CS) 

Screening for depression and other psychiatric disease. (PC, CS) 



Accurate recognition of signs that may indicate intoxication or withdrawal (e.g. behavioral or 

speech changes, changes in pupil size, conjunctival or nasal injection, tachycardia, 

sweating, piloerection, yawning, unsteady gait, etc.). (PC, MK) 

Examination of the nose for septal perforation as complication of cocaine use. (PC, MK) 

Examination of the skin for track marks or signs of needle use. (PC, MK) 

Identification of stigmata of secondary disease states (e.g. cirrhosis – splenomegaly, 

gynecomastia, telangiectasias, caput medusa, etc.) (PC, MK) 

Assessing for signs of endocarditis (e.g., fever, murmur, rash, etc). (PC, MK) 

Obtaining full mental status examination. (PC, MK) 


recognizing history, physical exam and/or laboratory findings to determine the diagnosis of 

abuse of drugs or alcohol and their sequelae. (PC, MK) 






Blood alcohol level. (PC, MK) 

Urine and serum toxicology screens. (PC, MK) 


Amylase and lipase levels. (PC, MK) 

Tests for HIV, hepatitis B and hepatitis C. (PC, MK) 

CBC. (PC, MK) 



Communicate the evaluation, treatment plan, and subsequent follow up to the patient and 

his or her family in a non-judgmental manner. (PC, CS) 

Elicit questions from the patient and his or her family about the disease process and 

management plan. (PC, CS) 

Counsel patients regarding cessation and available community referral resources. (PC, CS, 

SBP) 


treatment plan that includes: 

Assessing the patient’s motivation for achieving sobriety/abstinence. (PC, MK) 

Understanding the principles of acute management of drug/alcohol intoxication and 

withdrawal versus long-term treatment planning. (MK, PC) 

Using Clinical Institute Withdrawal Assessment for Alcohol. (CIWA-Ar) scale in acute 

alcohol withdrawal to prevent seizures or delirium tremens (MK, PC) 

Recommending appropriate use of benzodiazepines for alcohol withdrawal. (MK, PC) 

186

Determining when to obtain consultation from a psychiatrist. (PC, SBP) 


issues related to substance abuse. (PC, PLI) 

Incorporating patient preferences and understanding limitations of treatment. (PC) 



considerations in the selection of diagnostic and therapeutic interventions for substance abuse. (PLI, 

P) 

2. Respond appropriately to patients who are non-adherent to treatment for substance abuse. 

(CS, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding substance abuse. (PLI, 

P) 

4. Appreciate the impact substance abuse has on a patient’s as well as a family’s quality of life, 

well-being, and ability to work. (P) 


professions in the treatment of substance abuse. (P, SBP) 


U.S. Preventive Services Task Force. Screening and behavioral counseling 

interventions in primary care to reduce alcohol misuse recommendation statement. Ann 

Intern Med. 2004;140:554-6. 

Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 

2003;348:1786-95. 

Mersy DJ. Recognition of alcohol and substance abuse. Am Fam Physician. 

2003;67:1529-32. 

187

TRAINING PROBLEM #33: VENOUS THROMBOEMBOLISM 

RATIONALE: 

Venous thromboembolic disease (DVT and PE) is a very common problem in internal medicine and 

one that can have devastating consequences if not appropriately diagnosed and treated. Diagnosis of 

DVT and PE can be especially challenging. Prophylactic measures are very effective but do not 

eliminate the risk. 



Ability to perform a complete medical history and physical exam (with particular attention to the 

cardiac, pulmonary, and venous systems). 


Knowledge of the anatomy, physiology, and pathophysiology of the cardiac, pulmonary, and 

venous systems. 

Physiology and pathophysiology of the hemostatic system. 

Pharmacology of antithrombotic agents. 



1. Risk factors for developing DVT, including: 

Prior history of DVT/PE. (MK) 

Immobility/hospitalization. (MK) 

Increasing age. (MK) 

Obesity. (MK) 

Trauma. (MK) 

Smoking. (MK) 

Surgery. (MK) 

Cancer. (MK) 

Acute MI. (MK) 

Stroke and neurologic trauma. (MK) 

Coagulopathy. (MK) 

Pregnancy. (MK) 

Oral estrogens. (MK) 

2. Genetic considerations predisposing to venous thrombosis. (MK) 

3. The symptoms and signs of DVT and PE. (MK) 

4. The differential diagnosis of DVT including the many causes of unilateral leg pain and swelling: 

Venous stasis and the postphlebitic syndrome. (MK) 

Lymphedema. (MK) 

Cellulitis. (MK) 

Superficial thrombophlebitis. (MK) 

Ruptured popliteal cyst. (MK) 

Musculoskeletal injury. (MK) 

Arterial occlusive disorders. (MK) 

5. The differential diagnosis of PE including the many causes of chest pain and dyspnea: 

188

MI/unstable angina. (MK) 

Congestive heart failure. (MK) 

Pericarditis. (MK) 

Pneumonia/bronchitis/COPD exacerbation. (MK) 

Asthma. (MK) 

Pulmonary hypertension. (MK) 

Pneumothorax. (MK) 

Musculoskeletal pain (e.g. rib fracture, costochondritis). (MK) 

6. Treatment modalities for DVT/PE, including: 

Unfractionated heparin. (MK) 

Low-molecular-weight heparin. (MK) 

Warfarin. (MK) 

Thrombolytics. (MK) 

7. The risks, benefits, and indications for inferior vena cava filters. (MK) 

8. The long-term sequelae of DVT and PE. (MK) 

9. Methods of DVT/PE prophylaxis, their indications and efficacy, including: 

Ambulation. (MK) 

Graded compression stockings. (MK) 

Pneumatic compression devices. (MK) 

Unfractionated heparin. (MK) 

Low-molecular-weight heparin. (MK) 

Warfarin. (MK) 


1. History-taking skills: Students should be able to obtain, document and present an ageappropriate 

medical history that suggests the diagnosis of DVT or PE, including: 

The presence or absence of known risk factors. (PC, CS) 

Presence or absence of leg pain, swelling, warmth, discoloration, and palpable cord. (PC, 

CS) 

The presence or absence of dyspnea, chest pain, palpitations, cough, hemoptysis. (PC, 

CS) 

2. Physical exam skills: Students should be able to perform a physical examination to 

establish the diagnosis and severity of disease, including: 

Assessment of vital signs (i.e. hypotension, tachycardia, tachypnea, fever) and general 

appearance (i.e. degree of respiratory distress, anxiety). (PC) 

Accurate identification of leg swelling, erythema, warmth, and tenderness. (PC) 

Inspection for signs of lower extremity trauma, arthritis, or joint effusion. (PC) 

Identification of pleural friction rubs, wheezes, rales, rhonchi, and signs of pneumothorax. 

(PC) 


for a patient suspected of having DVT/PE, recognizing specific history, physical examination 

and laboratory findings which suggest DVT/PE, including the disease states noted above. (PC, 

MK) 



based on 

189

the differential diagnosis, including consideration of test cost and performance characteristics 

as well as patient preferences. 

Laboratory and diagnostic tests should include, where appropriate: 

Pulse oximetry. (PC, MK) 



ABG. (PC, MK) 

D-dimer. (PC, MK) 



Duplex venous ultrasonography. (PC, MK) 

Ventilation perfusion (V/Q) scan. (PC, MK) 

CT angiography. (PC, MK) 

Pulmonary angiography. (PC, MK) 







Perform a 12-lead ECG. (PC) 




Outlining the acute and long-term treatment of isolated calf vein phlebitis, superficial 

thrombophlebitis, DVT, and thromboembolism, including appropriate use and monitoring of 

heparin and warfarin. (MK, 

PC) 

Understanding the indications for placement of inferior vena cava filter, indications and 

complications of thrombolytic therapy, as well as indications for performing a 

hypercoaguability work-up. (PC, MK) 

Determining when to obtain consultation from a pulmonologist or interventional radiologist. 

(PC, MK) 



issues related to venous thromboembolism. (PC, PLI) 




considerations in the selection of diagnostic and therapeutic interventions for venous 

thromboembolic disease. (PLI, P) 

2. Respond appropriately to patients who are non-adherent to treatment for venous 

thromboembolic disease. (CS, P) 

3. Demonstrate ongoing commitment to self-directed learning regarding venous thromboembolic 

disease. (PLI, P) 

4. Appreciate the impact venous thromboembolic disease has on a patient’s quality of life, well- 

190

eing, ability to work, and the family. (P) 


professions in the treatment of venous thromboembolic disease. (P, SBP) 


American College of Chest Physicians. The seventh ACCP conference on 

antithrombotic and thrombolytic therapy: evidence-based guidelines. Chest. 2004;126 

(Number 3 Supplement) 

www.chestjournal.org/content/vol126/3_suppl 

Spyropoulos AC. Emerging strategies in the prevention of venous thromboembolism in 

hospitalized medical patients. Chest. 2005;128:958-69. 

Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK, Bharadia V, Kalra 

NK. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a 

systematic review. Ann Intern Med. 2004;140:589-602. 

Bates SM, Ginsberg JS. Clinical practice. Treatment of deep-vein thrombosis. N Engl J 

Med. 2004;351:268-77. 

Fedullo PF. Tapson VF. Clinical practice. The evaluation of suspected pulmonary 

embolism. N Engl J Med. 2003;349:1247-56. 

191

GENERAL CLINICAL CORE COMPETENCIES IN INTERNAL MEDICINE 

#1 DIAGNOSTIC DECISION MAKING 

RATIONALE: 

Physicians are responsible for directing and conducting the diagnostic evaluation of a broad range of 

patients, including patients seeking advice on prevention of and screening for disease and patients 

with acute and chronic illnesses. In a time of rapidly proliferating tests, medical students must learn 

how to design safe, expeditious, and cost-effective diagnostic evaluations. This requires welldeveloped 

diagnostic decision-making skills that incorporate probability-based thinking. 



Required course in pathophysiology. 

Required course in clinical epidemiology and biostatistics. 





1. Key history and physical examination findings pertinent to the differential diagnosis. (MK) 

2. Information resources for determining diagnostic options for patients with common and 

uncommon medical problems. (MK, PLI) 

3. Key factors to consider when selecting from among diagnostic tests, including pretest 

probabilities, performance characteristics of tests (sensitivity, specificity, likelihood ratios), cost, 

risk, and patient preferences. (MK, P) 

4. The basics of the potential role of genetic information in diagnostic decision making. (MK) 

5. Relative cost of diagnostic tests. (MK) 

6. How critical pathways or practice guidelines can be used to guide diagnostic test ordering. 

(MK) 

7. The methods of deductive reasoning, forward thinking, and pattern recognition in clinical 

decision making. (MK) 


1. Identifying problems with which a patient presents, appropriately synthesizing these into logical 

clinical syndromes. (PC) 

2. Identifying which problems are of highest priority. (PC) 

3. Formulating a differential diagnosis based on the findings from the history and physical 

examination. (PC) 

4. Using probability-based thinking and pattern recognition to identify the most likely diagnoses. 

(PC) 

5. Using the differential diagnosis to help guide diagnostic test ordering and sequencing. (PC) 

6. Using pretest probabilities and scientific evidence about performance characteristics of tests 

(sensitivity, specificity, likelihood ratios) to determine post-test probabilities according to the 

predictive value paradigm. (PC) 

7. Participating in selecting the diagnostic studies with the greatest likelihood of providing useful 

results at a reasonable cost. (PC) 

192

8. Communicating the prioritized differential diagnosis to the patient and his or her family. (CS) 


1. Incorporate the patient’s perspective into diagnostic decision making. (P) 

2. Recognize the importance of patient preferences when selecting among diagnostic tests. (P) 


considerations in the selection of diagnostic tests. (PLI, P) 

4. Seek feedback regularly regarding diagnostic decision making and respond appropriately and 

productively. (P) 

5. Limit the chances of false positive/false negative results by demonstrating thoughtful test 

selection. (P) 

6. Appreciate the element of uncertainty in diagnostic testing, including the occurrence and 

causes of false positive and false negative results. (P) 

7. Appreciate the impact uncertainty may have on the patient. (P) 


care professionals in diagnostic decision making. (P, SBP) 


Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald EB, Fauci AS, Hauser 

SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16th ed. New York, NY: 

McGraw-Hill; 2005:6-13. 

Strauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence Based Medicine: How to Practice 

and Teach EBM. 3rd ed. New York, NY: Churchill Livingstone; 2005. 

Primer to the Internal Medicine Clerkship A Guide Produced by the Clerkship Directors in Internal 

Medicine Clerkship Directors in Internal Medicine 

www.im.org/CDIM/primer.htm 

Ferri FF. Differential diagnosis. In Ferri FF, ed. Practical Guide to the Care of the Medical Patient. 

6th ed. St. Louis, MO: Mosby; 2004:39-113. 

193

#2 CASE PRESENTATION 

GENERAL CLINICAL CORE COMPETENCIES 

RATIONALE: 

Communicating patient care information to colleagues and other health care professionals is an 

essential skill regardless of specialty. Internists have traditionally given special attention to case 

presentation skills because of the comprehensive nature of patient evaluations and the various 

settings in which internal medicine is practiced. Students should develop facility with different types 

of case presentations: written and oral, new patient and follow-up, inpatient and outpatient. 







1. Components of comprehensive and abbreviated case presentations (oral and written) 

and settings appropriate for each. (MK) 


1. Prepare legible, comprehensive, and focused new patient workups that include the 

following features as clinically appropriate: 

Chief complaint. (PC, CS) 

Identifying data. (PC, CS) 

Concise history of the present illness organized chronologically, with minimal repetition, 

omission, or extraneous information, and including pertinent positives and negatives. 

(PC, CS) 

Past medical history, including relevant details. (PC, CS) 

Medications with dosages and frequencies, including herbals, supplements, and overthe-counter 

medications. (PC, CS) 

Allergies with specific details of the reaction. (PC, CS) 

Substance use, including tobacco, alcohol, and illicit drugs. (PC, CS) 

Family history. (PC, CS) 

Social history. (PC, CS) 

Review of symptoms. (PC, CS) 

A comprehensive physical examination with detail pertinent to the patient’s problem. 

(PC, CS) 

A succinct, prioritized, and where appropriate complete list of all problems identified by 

the history and physical examination. (PC, CS) 

A differential diagnosis (appropriate for the student’s level of training) for each problem 

that is neither over-inclusive or under-inclusive, addresses all reasonable possibilities, 

pays special attention to diagnoses that are potentially the most serious or lifethreatening, 

and is supported by the use of pertinent positives and negatives. (PC, CS) 

194

A diagnostic and treatment plan for each problem (appropriate for the student’s level of 

training). (PC, CS) 

2. Orally present a new inpatient’s or outpatient’s case in a manner that includes the 

following characteristics: 

Logically and chronologically develops the history of the present illness and tells the 

patient’s “story.” (PC, CS) 

Summarizes the pertinent positives and negatives. (PC, CS) 

Succinctly presents past medical history, family history, social history, and review of 

symptoms. (PC, CS) 

Includes a logical, organized, and prioritized differential diagnosis. (PC, CS) 

Includes diagnostic and therapeutic plans. (PC, CS) 

Can be made briefer when necessary. (PC, CS) 

Is presented as much from memory as possible with minimal reference to memory 

aids with the exception of highly important dates, diagnostic tests, laboratory values. 

(PC, CS) 

3. Orally present a follow-up inpatient’s or outpatient’s case in a manner that includes the 


Focused and very concise. (PC, CS) 

Problem-based. (PC, CS) 

Emphasizes pertinent new findings. (PC, CS) 



Is presented as much from memory as possible with minimal reference to memory 

aids with the exception of highly important dates, diagnostic tests, laboratory values. 

(PC, CS) 

4. Produce inpatient or outpatient progress notes in a manner that includes the following 

characteristics: 

Is appropriately titled. (PC, CS) 

Includes a brief subjective that addresses new or changed patient symptoms. (PC, 

CS) 

Provides an accurate and succinct accounting of the objective data 

(e.g. vital signs, in/outs, telemetry monitoring, focused physical examination, 

laboratory results, and diagnostic tests). (PC, CS) 

Includes a prioritized problem list with a concise assessment and plan for each. (PC, 

CS) 

5. Select the mode of presentation that is most appropriate to the clinical situation (e.g. 

written vs. oral, long vs. short, etc.). (PC, CS) 


1. Demonstrate ongoing commitment to self-directed learning regarding case presentation 

skills by regularly seeking feedback on presentations. (PLI, P) 

2. Respond appropriately and productively to feedback regarding performance. 

(P) 

3. Accurately and objectively record and present all data. (P) 

195

4. Demonstrate respect for the patient’s privacy when dealing with protected health 

information and follow Health Information Portability and Accountability Act (HIPAA) 

standards. (P) 


Primer to the Internal Medicine Clerkship A Guide Produced by the Clerkship Directors in 

Internal Medicine Clerkship Directors in Internal Medicine 

www.im.org/CDIM/primer.htm 

Sobel RK. MSL – medicine as a second language. N Engl J Med. 2005;352:1945 

196


#3 HISTORY TAKING AND PHYSICAL EXAMINATION 

RATIONALE: 

The ability to obtain an accurate medical history and carefully perform a physical examination is 

fundamental to providing comprehensive care to adult patients. In particular, the internist must be 

thorough and efficient in obtaining a history and performing a physical examination with a wide variety 

of patients, including healthy adults (both young and old), adults with acute and chronic medical 

problems, adults with complex life-threatening diseases, and adults from diverse socioeconomic and 

cultural backgrounds. The optimal selection of diagnostic tests, choice of treatment, and use of 

subspecialists, as well as the physician’s relationship and rapport with patients, all depend on welldeveloped 

history-taking and physical diagnosis skills. These skills, which are fundamental to 

effective patient care, should be a primary focus of the student’s work during the core clerkship in 

internal medicine. 


Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience 

should include: 

Required pre-clinical courses in physical examination and physician-patient 

communication (should include instruction in breast, pelvic, rectal, and male genital exams). 

Ability to perform a complete medical history and physical exam on a wide variety of 

patients including adolescents and older adults. 

Ability to effectively communicate with patients of diverse backgrounds. 

Basic skills for obtaining a history related to substance abuse, sexual, occupational, 

and mental health. 



1. The significant attributes of a symptom, including: location and radiation, intensity, quality, 

temporal sequence (onset, duration, frequency), alleviating factors, aggravating factors, 

setting, associated symptoms, functional impairment, and patient’s interpretation of symptom. 

(MK) 

2. The four methods of physical examination (inspection, palpation, percussion, and 

auscultation), including where and when to use them, their purposes, and the findings they 

elicit. (MK) 

3. The physiologic mechanisms that explain key findings in the history and physical exam. (MK) 

4. The diagnostic value of the history and physical examination. (MK) 


1. Using language appropriate for each patient. (PC, CS) 

2. Using non-verbal techniques to facilitate communication and pursue relevant inquiry. (PC, CS) 

3. Eliciting the patient’s chief complaint as well as a complete list of the patient’s concerns. 

(PC,CS) 

4. Obtaining a patient’s history in a logical, organized, and thorough manner, covering the 

following: 

197

History of present illness. (PC, CS) 

past medical history (including usual source of and access to health care, childhood and 

adult illnesses, injuries, surgical procedures, obstetrical history, psychiatric problems, 

sexual history, and hospitalizations). (PC, CS) 

Preventive health measures. (PC, CS) 

Medications with dosages and frequencies, including herbals, supplements, and overthe-counter 

medications. (PC, CS) 

Allergies with specific details of the reaction. (PC, CS) 

Substance use including tobacco, alcohol, and illicit drugs. (PC, CS) 

Family history. (PC, CS) 

Social history. (PC, CS) 

Occupational history. (PC, CS) 

Review of symptoms. (PC, CS) 

5. Obtaining, whenever necessary, supplemental historical information from collateral sources, 

such as significant others or previous physicians. (PC, CS) 

6. Demonstrating proper hygienic practices whenever examining a patient. (PC) 

7. Positioning the patient and self properly for each part of the physical examination. (PC) 

8. Performing a physical examination for a patient in a logical, organized, respectful, and 

thorough manner, including: 

The patient’s general appearance. (PC) 

Vital signs. (PC) 

Pertinent body regions/organ systems. (PC) 

When appropriate breast, pelvic, rectal, male genital exams. (PC) 

When appropriate fundoscopic exam. (PC) 

When appropriate full neurologic exam. (PC) 

9. Adapting the scope and focus of the history and physical exam appropriately to the medical 

situation and the time available. (PC) 

10. Being observant of the patient’s modesty as much as possible. (PC, P) 


1. Appreciate the essential contribution of a pertinent and history and physical examination 

to patient care. (P) 

2. Demonstrate ongoing commitment to self-directed learning regarding history taking and 

physical examination skills. (PLI, P) 

3. Seek feedback regularly regarding history and physical examination skills and respond 

appropriately and productively. (P) 


health care professions in obtaining a history and physical examination (e.g. interpreter 

services, advanced practice nurses, etc.). (P, SBP) 

5. Establish a habit of updating historical information and repeating important parts of the 

physical examination during follow-up visits. (P) 

6. Demonstrate consideration for the patient’s modesty, feelings, limitations, and 

sociocultural background whenever taking a history and performing a physical 

examination. (P) 

7. Appreciate that some patients will be very anxious about the physical examination, 

particularly the breast, pelvic, rectal, and male genital exams. (P) 


198

McGee SR. Evidence-Based Physical Diagnosis. Philadelphia, PA: W. B. Saunders Company; 

2001. 

Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking. 8th Edition. 

Philadelphia, PA: Lipincott Williams and Wilkens; 2002. 

The Auscultation Assistant 

www.med.ucla.edu/wilkes/intro.html 

Criley JM. The Physiologic Origin of Heart Sounds and Murmurs: The Unique Interactive Guide 

to Cardiac Diagnosis. Philadelphia, PA: Lippincott Williams and Wilkins; 1997. 

Heart Sounds and Cardiac Arrhythmias 

Medical Multimedia Laboratories 

www.blaufuss.org 

199


#4 COMMUNICATION AND RELATIONSHIPS WITH PATIENTS AND COLLEAGUES 

RATIONALE: 

The physician-patient relationship forms the core of the practice of internal medicine. Many 

physicians view it as the most satisfying aspect of their work. The medical interview and the 

relationship between physician and patient are important diagnostic and therapeutic tools. Effective 

communication skills are needed for a physician to serve as an effective patient advocate. 

Communication skills also are needed to address patient concerns and requests. Proficiency in 

communicating with patients results in increased patient and physician satisfaction, increased 

adherence to therapy, and reduced risk of malpractice claims. The student on the internal medicine 

clerkship interacts with a diverse array of patients, physicians, and other health team members, 

necessitating proficiency in communication and interpersonal skills. Students also witness how 

diversities of age, gender, race, culture, socioeconomic class, personality, and intellect require a 

sensitive and flexible approach. The result of proficiency in communication and interpersonal skills is 

increased satisfaction for both doctor and patient. 


Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should 

include: 

Required pre-clinical courses in physician-patient communication. 

Ability to perform a complete medical history on a wide variety of patients, including adolescents 

and older adults. 


Basic skills for obtaining a history related to substance abuse and sexual, occupational, and 

mental health. 

Basic skills for discussing issues relating to advance directives. 

Basic skills for breaking bad news. 



1. How patients’ and physicians’ perceptions, preferences, and actions are affected by 

cultural and psychosocial factors and how these factors affect the doctor-patient 

relationship. (MK, P) 

2. The role and contribution of each team member to the care of the patient. (MK, SBP) 

3. The role of psychosocial factors in team interactions. (MK) 

4. The role of the physician as patient advocate. (MK) 

5. Strategies for establishing positive patient-doctor relationships. (MK) 

6. Patient, physician, and system barriers to successfully negotiated treatment plans and 

patient adherence; strategies that may be used to overcome these barriers. (MK, SBP) 

6. Useful strategies when a communicating with patients via an interpreter. (MK) 

7. Basic techniques for breaking bad news. (MK) 

8. Basic tenants of genetic counseling. (MK) 


200

1. Demonstrating appropriate listening skills, including verbal and non-verbal techniques 

(e.g., restating, probing, clarifying, silence, eye contact, posture, touch) to communicate 

empathy and help educate the patient. (CS) 

2. Demonstrating effective verbal skills including appropriate use of open- and closedended 

questions, repetition, facilitation, explanation, and interpretation. (CS) 

3. Determining the information a patient has independently obtained about his or her 

problems. (CS) 

4. Identifying patients’ emotional needs. (CS) 

5. Respond to empathic opportunities by naming the emotions or feelings expressed. (CS) 

6. Eliciting the patient’s point of view and concerns about his or her illness and the medical 

care he or she is receiving. (CS) 

7. Discussing how the health problem affects the patient’s life. (CS) 

8. Determining the extent to which a patient wants to be involved in making decisions 

about his or her care. (CS) 

9. Providing basic information and an explanation of the diagnosis, prognosis, and 

treatment plan. (CS) 

10. Responding to patients’ concerns and expectations. (CS) 

11. With guidance and direct supervision, participating in breaking bad news to patients. 

(CS) 

12. With guidance and direct supervision, participating in discussing basic issues regarding 

advance directives with patients and their families. (CS) 

13. With guidance and direct supervision, participating in discussing basic end-of life issues 

with patients and their families. (CS) 

14. Assessing patient commitment and adherence to a treatment plan taking into account 

personal and economic circumstances. (CS) 

15. Working with a variety of patients, including multi-problem patients, angry patients, 

somatizing patients, and substance abuse patients. (CS) 

16. Working as an effective member of the patient care team, incorporating skills in interprofessional 

communication and collaboration. (CS, SBP) 

17. Giving and receiving constructive feedback. (CS) 

18. Orally presenting a new inpatient’s or outpatient’s case in a manner that includes the 


Logically and chronologically develops the history of the present illness and tells 

the patient’s “story.” (PC, CS) 

Summarizes the pertinent positives and negatives. (PC, CS) 

Succinctly presents past medical history, family history, social history, and review 

of symptoms. (PC, CS) 

includes a logical, organized, and prioritized differential diagnosis (PC, CS) 



Is presented as much from memory as possible with minimal reference to 

memory aids with the exception of highly important dates, diagnostic tests, 

laboratory values. (PC, CS) 

19. Orally presenting a follow-up inpatient’s or outpatient’s case in a manner that includes 

the following characteristics: 

Is focused, very concise, and problem-based. (PC, CS) 

Emphasizes pertinent new findings. (PC, CS) 


201


Is presented as much from memory as possible with minimal reference to 

memory aids with the exception of highly important dates, diagnostic tests, and 

laboratory values. (PC, CS) 

20. Demonstrating the ability to make clear and concise presentations about topics 

assigned to research. (CS) 

21. Demonstrating basic strategies for conflict management and resolution. (CS) 

22. Demonstrating basic techniques of communication with non-English speaking patient 

via an interpreter. (PC, CS) 


1. Demonstrate ongoing commitment to self-directed learning regarding effective doctorpatient 

communication skills. (PLI, P) 

2. Seek feedback regularly regarding communication skills and respond appropriately and 


3. take into consideration in each case the patient’s psychosocial status (P) 

4. Demonstrate respect for patients. (P) 

5. Involve the patient actively in his or her health care whenever possible. (P) 

6. Demonstrate teamwork and respect toward all members of the health care team, as 

manifested by reliability, responsibility, honesty, helpfulness, selflessness, and initiative 

in working with the team. (SBP, P) 

7. Attend to or advocate for the patient’s interests and needs in a manner appropriate to 

the student’s role. (P) 

8. Maintain confidentiality when dealing with protected health information and follow Health 

Information Portability and Accountability Act (HIPAA) guidelines. (P, SBP) 


Clinician-Patient Communication to Enhance Health Outcomes. Institute for Health Care 

communication, Inc., West Haven, Connecticut, 1998. 

www.healthcarecomm.org 

Contemporary Issues in Medicine: Communication in Medicine Medical School Objectives 

Project, October 1999 American Association of Medical Colleges 

www.aamc.org/meded/msop/msop3.pdf 

Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. 

Oxford: Radcliffe Medical Press Ltd; 1998. 

Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method 

teaching: enhancing the Calgary-Cambridge guides. Acad Med. 2003;78:802-9. 

Makoul G. The SEGUE Framework for teaching and assessing 

communication skills. Patient Educ Couns. 2001;45:23-34. 

Makoul G. Essential elements of communication in medical encounters: the Kalamazoo 

consensus statement. Acad Med. 2001;76:390-3. 

von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care: 

communication and relational skills. JAMA. 2000;284:3051-7. 

202


#5 INTERPRETATION OF CLINICAL INFORMATION 

RATIONALE: 

In the routine course of clinical practice, most physicians are required to order and interpret a wide 

variety of diagnostic tests and procedures. Determining how these test results will influence clinical 

decision making and communicating this information to patients in a timely and effective manner are 

core clinical skills that third-year medical students should possess. 



Introductory course in clinical pathology and laboratory medicine. 

Introductory course in epidemiology and biostatistics. 


A. KNOWLEDGE: Students should be able to: 

1. Interpret specific diagnostic tests and procedures that are ordered to evaluate patients who 

present with common symptoms and diagnoses encountered in the practice of internal 

medicine. (PC, MK) 

2. Take into account: 

Important differential diagnostic considerations, including potential diagnostic 

emergencies. (PC, MK) 


Performance characteristics of individual tests. (sensitivity, specificity, positive and 

negative predictive value, likelihood ratios). (PC, MK) 

3. Define and describe for the tests and procedures listed: 

Indications for testing. (PC, MK) 

Range of normal variation. (PC, MK) 

Critical values that require immediate attention. (PC, MK) 

Pathophysiologic implications of abnormal results. (PC, MK) 

Relative cost. (MK, SBP) 

4. Independently interpret the results of the following laboratory tests: 

CBC with diff and blood smear. (PC, MK) 

UA. (PC, MK) 

Electrolytes. (PC, MK) 

BUN/Cr. (PC, MK) 

GLC. (PC, MK) 


Hepatitis serologies. (PC, MK) 

Cardiac biomarkers (e.g. myoglobin, CK-MB, and Troponin I/T). (PC, MK) 

Routine coagulation tests (e.g. PT/PTT and INR). (PC, MK) 

Thyroid function tests (e.g. T3, T4, and TSH). (PC, MK) 

ABG.(PC, MK) 

Body fluid cell counts and chemistries. (PC, MK) 

5. Independently interpret the results of the following diagnostic procedures: 

203



Plain abdominal films (e.g. obstructive series, KUB). (PC, MK) 


6. Describe the basic electrophysiologic events that produce the surface ECG. (MK) 

7. Describe how errors in test interpretation can affect clinical outcomes and costs. (PC, MK) 

8. Describe the concept of a threshold as it relates to testing and treatment decisions. (PC, MK) 

9. Describe the basic principles of using genetic information in clinical decision making. (PC, MK) 


1. Interpreting a blood smear, Gram stain, and UA. (PC) 

2. Approaching ECG interpretation in a systematic and logical fashion analyzing the following: 

rate, rhythm, P wave morphology, PR interval, QRS width, axis, voltage, QT interval, ST 

segment morphology, and T wave morphology. (PC) 

3. Recognizing the following on ECG: 

Sinus tachycardia, sinus bradycardia, sinus arrhythmia. (PC) 

Premature atrial beats, ectopic atrial rhythm/tachycardia, narrow complex supraventricular 

tachycardia. (PC) 

Multifocal atrial tachycardia, atrial flutter, atrial fibrillation (PC) 

First degree, second degree (Mobitz type I and II), and third degree (complete) heart 

block. (PC) 

Junctional rhythm. (PC) 

Premature ventricular beats. (PC) 

Typical ventricular tachycardia, ventricular fibrillation. (PC) 

Left and right atrial enlargement. (PC) 

Left ventricular hypertrophy. (PC) 

Left and right bundle branch block, left anterior and posterior fascicular block. (PC) 

The characteristic features of a properly functioning ventricular or dual chamber 

pacemaker. (PC) 

The delta wave in Wolf-Parkinson-White Syndrome. (PC) 

The classic features of myocardial ischemia and infarction and be able to localize the 

findings (i.e. inferior, anterior, lateral, posterior, right ventricular) and identify the probable 

culprit vessel. (PC) 

The classic features of pulmonary embolism. (PC) 

The characteristic effects of hypo- and hyperkalemia. (PC) 

4. Approaching chest radiography interpretation in a systematic and logical fashion analyzing the 

following: technique (e.g. view, rotation, exposure), visible abdomen, soft tissues and bones of 

the thorax, mediastinum/hila, and lungs. (PC) 

5. Recognizing the following on chest radiograph: 

Rib fracture. (PC) 

Cardiomegaly. (PC) 

Lobar pneumonia. (PC) 

Pleural effusion. (PC) 

Pneumothorax. (PC) 

Pulmonary nodule. (PC) 

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Pulmonary edema/“congestive heart failure” (e.g. cardiomegaly, pulmonary vascular 

redistribution, Kerley’s B Lines, interstitial/alveolar edema). (PC) 

Hilar lymphadenopathy. (PC) 

Mediastinal widening. (PC) 

6. Recording the results of laboratory tests in an organized manner, using flow sheets when 

appropriate. (PC) 

7. Estimating the pre-test likelihood of a disease or condition. (PC, MK) 

8. Estimating the post-test probability of disease and stating the clinical significance of the results 

of laboratory tests and diagnostic procedures. (PC, MK) 



considerations in the selection of diagnostic and therapeutic interventions for acute MI. (PLI, P, 

SBP) 

2. Regularly seek feedback regarding interpretation of clinical information and respond 

appropriately and productively. (P) 

3. Recognize the importance of patient preferences when selecting among diagnostic testing 

options. (P) 

4. Demonstrate ongoing commitment to self-directed learning regarding test interpretation. (PLI, 

P) 

5. Appreciate the implications of test results before ordering tests. (P) 

6. Appreciate the importance of follow-up on all diagnostic tests and procedures and timely 

communication of information to patients and appropriate team members. (P) 

7. Demonstrate a commitment to excellence by personally reviewing radiographs, ECGs, Gram 

stains, blood smears, etc. to assess the accuracy and significance of the results. (P) 


Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature. 

III. How to use an article about a diagnostic test. A. Are the results of the study valid? JAMA. 

1994; 271:389-91. 

Jaeschke R, Guyatt G, Sackett DL. Users’ guides to the medical literature. 

III. How to use an article about a diagnostic test. B. What are the results and will they help me 

in caring for my patients? JAMA. 1994; 271: 703-7. 

Dubin D. Rapid Interpretation of EKG's. 5th ed. Tampa, FL: Cover Publishing Company; 2000. 

Goodman LR. Felson’s Principles of Chest Roentgenology: A Programmed Text. 2nd ed. 

Philadelphia, PA: W. B. Saunders; 1999. 

Novelline RA. Squire's Fundamentals of Radiology. 6th ed. Cambridge, MA: University Press; 

2004. 

Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald EB, Fauci AS, 

Hauser SL, Longo DL, Jameson JL, eds. Harrison’s Principles of Internal Medicine. 16th ed. 

New York: McGraw-Hill; 2005:6-13. 

Lab Test Online 

www.labtestsonline.org/ 

RadQuiz: Your Gateway to Radiology Resources 

www.radquiz.com 

Introduction to Chest Radiology 

205

Department of Radiology 

University of Virginia Health Sciences Center 

www.med-ed.virginia.edu/courses/rad/cxr/index.html 

Ferri FF. Laboratory values and interpretation of results. In Ferri FF, ed. Practical Guide to 

the Care of the Medical Patient. 6th ed. St. Louis, MO: Mosby; 2004:935-976. 

206

#6 THERAPEUTIC DECISION MAKING 


RATIONALE: 

Internists are responsible for directing and coordinating the therapeutic management of patients with 

a wide variety of problems, including critically ill patients with complex medical problems and the 

chronically ill. To manage patients effectively, physicians need basic therapeutic decision-making 

skills that incorporate both pathophysiologic reasoning and evidence-based knowledge. 


Introductory coursework in clinical epidemiology and biostatistics. 

Introductory coursework in physiology and pathology. 

Introductory coursework in pharmacology. 



1. Information resources for determining medical and surgical treatment options for patients 

with common and uncommon medical problems. (MK) 

2. Key factors to consider in choosing among treatment options, including risk, cost, evidence 

about efficacy, and consistency with pathophysiologic reasoning (MK) 

3. How to use critical pathways and clinical practice guidelines to help guide therapeutic 

decision making. (MK) 

4. Factors that frequently alter the effects of medications, including drug interactions and 

compliance problems. (MK) 

5. Factors to consider in selecting a medication from within a class of medications. (MK) 

6. Factors to consider in monitoring a patient’s response to treatment, including potential 

adverse effects. (MK) 

7. Various ways that evidence about clinical effectiveness is presented to clinicians and the 

potential biases of using absolute or relative risk or number of patients needed to treat. (MK) 

8. Methods of monitoring therapy and how to communicate them in both written and oral form. 

(MK) 

9. The basics of the potential role of genetic information in therapeutic decision making. (MK) 


1. Formulating an initial therapeutic plan. (PC) 

2. Changing the therapeutic plan when goals of care change (e.g. a shift toward palliative 

care). (PC) 

3. Accessing and utilizing, when appropriate, information resources to help develop an 

appropriate and timely therapeutic plan. (PC, PLI) 

4. Explaining the extent to which the therapeutic plan is based on pathophysiologic reasoning 

and scientific evidence of effectiveness. (PC) 

5. Beginning to estimate the probability that a therapeutic plan will produce the desired 

outcome. (PC) 

6. Writing prescriptions and inpatient orders safely and accurately. (PC) 

7. Counseling patients about how to take their medications and what to expect 

when doing so, including beneficial outcomes and potential adverse effects. (PC, CS) 

207

8. Monitoring response to therapy. (PC) 

9. Recognizing when to seek consultation for additional diagnostic and therapeutic 

recommendations. (PC, SBP) 

10. Recognizing when to screen for certain conditions based on age and risk factors and what 

to do with the results of the screening tests. (PC) 



consideration in the selection of therapeutic interventions. (PLI, P) 

2. Demonstrate ongoing commitment to self-directed learning regarding therapeutic 

interventions. (PLI, P) 

3. Seek feedback regularly regarding therapeutic decision making and respond appropriately 

and productively. (P) 

4. Appreciate the impact therapeutic decisions have on a patient’s quality of life (P) 

5. Incorporate the patient in therapeutic decision making, explaining the risks and benefits of 

treatment. (CS, P) 

6. Respect patients’ autonomy and informed choices, including the right to refuse treatment. 

(P) 

7. Demonstrate an understanding of the importance of close follow-up of patients under active 

care. (P) 


health care professionals in therapeutic decision making. (P, SBP) 


Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald EB, Fauci AS, 



Roden DM. Principles of clinical pharmacology. In Kasper DL, Braunwald EB, Fauci AS, 



Users' guides to the medical literature. II. How to use an article about therapy or prevention. A. 

Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 

1993;270:2598-601. 

Users' guides to the medical literature. II. How to use an article about therapy or prevention. B. 

What were the results and will they help me in caring for my patients? Evidence-Based 

Medicine Working Group. JAMA. 1994;271:59-63. 

#7 BIOETHICS OF CARE 


RATIONALE: 

A basic understanding of ethical principles and their application to patient care is essential for all 

physicians. During the internal medicine core clerkship, the student can put into practice some of the 

ethical principles learned in the preclinical years, especially by participating in discussions of informed 

208

consent and advance directives. Additionally, the student learns to recognize ethical dilemmas and 

respect different perceptions of health, illness, and health care held by patients of various religious 

and cultural backgrounds. 


Introductory course on medical ethics providing a basic understanding of ethical principles and 

fiduciary relationships and their application in clinical medicine: 

Autonomy. 

Beneficence. 

Nonmaleficence. 

Truth-telling. 

Confidentiality. 

Respect for autonomy (informed choice). 



1. Basic ethical principles (autonomy, beneficence, nonmaleficence, truth-telling, confidentiality, 

and autonomy). (MK) 

2. The patient’s right to refuse care. (MK) 

3. The unique nature of a fiduciary relationship. (MK) 

4. Basic elements of informed consent. (MK) 

5. Circumstances under which informed consent is necessary and unnecessary (MK) 

6. Basic concepts of treatment efficacy, quality of life, and societal demands. (MK) 

7. Potential conflicts between individual patient preferences and societal demands (MK) 

8. The role of the physician in making decisions about the use of expensive or controversial tests 

and treatments. (MK) 

9. Bioethical concerns regarding genetic information, privacy issues in particular. (MK) 

10. The unique bioethical concerns regarding end-of-life care. (MK) 

11. Circumstances when withholding or withdrawing care is acceptable. (MK) 

12. The role of federal and state legislation in governing health care. (MK) 

13. Circumstances when it may be unavoidable or acceptable to breach the basic ethical 

principles. (MK) 


1. Participating in a discussion about advance directives with a patient. (PC, CS) 

2. Participating in obtaining informed consent for a procedure. (PC, CS) 

3. Participating in explaining and obtaining informed consent for genetic testing (PC, CS) 

4. Participating in a preceptor’s discussion with a patient about a requested 

treatment that may not be considered appropriate (e.g., not cost-effective). (PC, CS) 

5. Participating in family and interdisciplinary team conferences discussing endof-life 

care and incorporating the patient’s wishes in that discussion. (PC, CS, SBP) 

6. Obtaining additional help from ethics experts in conflict resolution. (PC, SBP) 


209

1. Demonstrate ongoing commitment to self-directed learning regarding bioethics. (PLI) 

2. Recognize the importance of patient preferences, perspectives, and perceptions regarding 

health and illness. (P) 

3. Demonstrate a commitment to caring for all patients, regardless of the medical diagnosis, 

gender, race, socioeconomic status, intellect/level of education, religion, political affiliation, 

sexual orientation, ability to pay, or cultural background. (P) 

4. Recognize the importance of allowing terminally ill patients to die with comfort and dignity 

when that is consistent with the wishes of the patient and/or the patient’s family. (P) 

5. Recognize the potential conflicts between patient expectations and medically appropriate care. 

(P) 

6. Respond appropriately to patients who are nonadherent to treatment. (P) 

7. Demonstrate respect for the patient’s privacy and confidentiality when dealing with protected 

health information and follow HIPAA standards. (P) 

8. Appreciate the psychological impact genetic information may have on patients. (P) 


Bioethics Resources on the Web 

Inter-Institute Bioethics Interest Group 



www.nih.gov/sigs/bioethics/ 

University of Pennsylvania Center for Bioethics 

www.bioethics.upenn.edu 

Snyder L, Leffler C, Ethics and Human Rights Committee, American College of Physicians. 

Ethics manual: fifth edition. Ann Intern Med. 2005;142:560-82. 

World Medical Association Ethics Unit 

www.wma.net/e/ethicsunit/resources.htm 

Ethics in Medicine University of Washington School of Medicine 

eduserv.hscer.washington.edu/bioethics 

Program in Ethics In Science and Medicine University of Texas Southwestern Medical Center 

www3.utsouthwestern.edu/ethics/ 

Virtual Mentor American Medical Association 

www.ama-assn.org/ama/pub/category/3040.html 

Bioethics Interest Group American Medical Student Association 

www.amsa.org/bio/index.cfm 

210

#8 SELF-DIRECTED LEARNING 


RATIONALE: 

Because of the breadth of the problems encountered in clinical practice, internists face an 

extraordinary challenge to keep up with the burgeoning amount of new information relevant to 

providing high quality care. Therefore, they must master and practice self-directed life-long learning, 

including the ability to access and utilize information systems and resources efficiently. 



Basic library skills, including the ability to perform an electronic literature search. 

Critical appraisal skills. 

Understanding of basic concepts of biostatistics and clinical epidemiology including: sensitivity, 

specificity, positive predictive value, negative predictive value, absolute risk reduction, relative 

risk reduction, number needed to treat, likelihood/odds ratios, and tests of significance. 



1. Key sources for obtaining updated information on issues relevant to the medical management 

of adult patients. (MK, PLI) 

2. A system for managing information from a variety of sources. (MK, PLI) 

3. The concept of the focused clinical question. (MK, PLI) 

4. Key questions to ask when critically appraising articles on diagnostic tests: 

Was there an independent, blind comparison with a reference (“gold”) standard? (MK, 

PLI) 

Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in 

whom it would be used in practice)? (MK, PLI) 

Was the reference standard applied regardless of the diagnostic test result? (MK, PLI) 

What were the results of the study (e.g. sensitivity, specificity, likelihood ratios, and/or 

pre- and post-test probabilities)? (MK, PLI) 

5. Key questions to ask when critically appraising articles on medical therapeutics: 

Was the assignment of patients to treatments randomized? (MK, PLI) 

Were all patients who entered the trial properly accounted for at the conclusion of the 

study and analyzed in the group they were randomized to? (MK, PLI) 

Were patients and study personnel blind to the treatment? (MK, PLI) 

Were the groups similar at the start of the trial? (MK, PLI) 

Aside from the experimental intervention, were the groups treated equally? (MK, PLI) 

What were the results of the trial (e.g. relative risk reduction, absolute risk reduction, and 

“number needed to treat”)? (MK, PLI) 


211

1. Performing a computerized literature search to find articles pertinent to a focused clinical 

question. (PLI) 

2. Demonstrating critical review skills. (PLI) 

3. Reading critically about issues pertinent to their patients. (PLI) 

4. Assessing the limits of medical knowledge in relation to patient problems (PLI) 

5. Using information from consultants critically. (PLI) 

6. Recognizing when additional information is needed to care for the patient (PLI) 

7. Asking colleagues (students, residents, nurses, faculty) for help when needed (PLI, SBP) 

8. Making use of available instruments to assess one’s own knowledge base (PLI, P) 

9. Summarizing and presenting to colleagues what was learned from consulting the medical 

literature. (PLI, CS) 


1. Demonstrate self-directed learning in every case. (PLI, P) 

2. Acknowledge gaps in knowledge to both colleagues and patients and request help. (PLI, P) 

3. Seek feedback regularly and respond appropriately and productively. (P) 

4. Recognize the value and limitations of other health care professionals when confronted with a 

knowledge gap. (PLI, P, SBP) 


Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine 

Working Group. JAMA. 1993;270:2093-5. 

Users' guides to the medical literature. II. How to use an article about therapy or prevention. A. 

Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 

1993;270:2598-601. 

Users' guides to the medical literature. II. How to use an article about therapy or prevention. B. 

What were the results and will they help me in caring for my patients? Evidence-Based 


Users' guides to the medical literature. III. How to use an article about a diagnostic test. A. Are 

the results of the study valid? Evidence-Based Medicine Working Group. JAMA. 

1994;271:389-91. 

Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. 

What are the results and will they help me in caring for my patients? The Evidence-Based 


Strauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence Based Medicine: How to 

Practice and Teach EBM. 3rd ed. New York, NY: Churchill Livingstone; 2005. 

Advancing Education in Practice-Based Learning and Improvement An Educational Resource 

from the ACGME Outcome Project 

www.acgme.org/outcome/implement/complete_PBLIBooklet.pdf 

#9 PREVENTION 


RATIONALE: 

One of the most important responsibilities of primary care physicians is to promote health and prevent 

disease in a cost-effective manner. Appropriate care by internists includes not only recognition and 

212

treatment of disease but also the routine incorporation of the principles of preventive health care into 

clinical practice. All physicians should be familiar with the principles of preventive health care to 

ensure their patients receive appropriate preventive services. 



Introductory course in clinical epidemiology and biostatistics. 

Introductory course in health promotion and disease prevention. 





1. Primary, secondary, and tertiary prevention. (MK) 

2. Criteria for determining whether or not a screening test should be incorporated into the periodic 

health assessment of adults. (MK) 

3. General types of preventive health care issues that should be addressed on a routine basis in 

adult patients (i.e., cancer screening; prevention of infectious diseases, coronary artery 

disease, osteoporosis, and injuries; and identification of substance abuse). (MK) 

4. Vaccines that have been recommended for routine use in at least some adults (i.e., influenza, 

pneumococcal, measles, mumps, rubella, tetanus-diphtheria, hepatitis). (MK) 

5. Indications for endocarditis prophylaxis. (MK) 

6. Methods for counseling patients about risk-factor modification, including the “stages of change” 

approach to helping patients change behavior. (MK) 

7. Influence of age and clinical status on approach to prevention. (MK) 

8. General categories of high-risk patients in whom routine preventative health care must be 

modified or enhanced (e.g., family history, travel to an underdeveloped area, occupational 

exposures, etc.). (MK) 

9. The major areas of controversy in screening. (MK) 

10. The potential roles and limitations of genetic testing in disease 

prevention/early detection. (MK) 


1. Obtaining a patient history, including a detailed family history, vaccination history, travel 

history, sexual history, and occupational exposures. (PC) 

2. Identifying patients at high risk for developing diabetes, dyslipidemia, coronary artery disease, 

cancer, osteoporosis, influenza, pneumonia, hepatitis, HIV infection, and tuberculosis by 

screening for major risk factors. (PC) 

3. Obtaining a Pap smear and interpreting its results. (PC) 

4. Performing a breast examination. (PC) 

5. Instructing patients to perform breast self-examination. (PC, CS) 

6. Interpreting the results of a mammogram. (PC) 

7. Performing a digital rectal examination. (PC) 

8. Interpreting the results of a PSA test and understand its limitations. (PC) 

9. Performing a testicular examination. (PC) 

10. Interpreting the results of a bone densitometry test. (PC) 

11. Interpreting the results of a fasting lipid profile. (PC) 

213

12. Interpreting the results of a fasting glucose test. (PC) 

13. Counseling patients about safe-sex practices, smoking cessation, alcohol abuse, weight loss, 

healthy diet, exercise, and seat belt use. (PC, CS) 

14. place and interpret a PPD. (PC) 

15. Locating recently published recommendations as well as original data regarding measures that 

should be incorporated into the periodic health assessment of adults. (PLI) 


1. Address preventive health care issues as a routine part of their assessment of patients. (P) 

2. Encourage patients to share responsibility for health promotion and disease prevention. (P) 

3. Recognize the importance of patient preferences when recommending preventive health 

measures. (P) 

4. Understand the patient’s right to refuse preventive health measures. (P) 


considerations in the selection preventive health measures. (PLI, P) 

6. Demonstrate ongoing commitment to self-directed learning regarding preventive health 

measures. (PLI, P) 


Pomrehn PR, Davis MV, Chen DW, Barker W. Prevention for the 21st century: setting the 

context through undergraduate medical education. Acad Med. 2000;75(7 Suppl):S5-13. 

Guide to Clinical Preventive Services 

U.S. Preventative Services Task Force (USPSTF) 



USPSTF Recommendation: Screening for Cancer 

www.ahrq.gov/clinic/cps3dix.htm#cancer 

USPSTF Recommendation: Screening for Lipid Disorders 

www.ahrq.gov/clinic/ajpmsuppl/lipidrr.htm 

USPSTF Recommendation: Screening for High Blood Pressure 

www.ahrq/clinic/3rduspstf/highbloodsc/hibloodrr.htm 

USPSTF Recommendations Statement: Counseling to prevent tobacco use and tobaccocaused 

disease 

www.ahrq.gov/clinic/3rduspstf/tobaccoun/tobcounrs.htm 

Screening for Prostate Cancer. American College of Physicians. Ann Int Med 1997; 126: 480- 

484. 

Summary of Recommendations for Adult Immunization Immunization Action Coalition Bulletin 

Adapted from the recommendations of the Advisory Commttee on Immunization Practices 

(ACIP), August 2005 

www.immunize.org/acip 

Martin GJ. Screening and prevention of disease. In Kasper DL, Braunwald EB, Fauci AS, 

Hauser SL, Longo DL, and Jameson JL eds. Harrison’s Principles of Internal Medicine. 16th 


214

#10 COORDINATION OF CARE 


RATIONALE: 

The task of coordinating a patient’s care is central to the role of the internist, and involves 

communication with the patient and his or her family, colleagues, consultants, nurses, social workers, 

and community-based agencies. It is essential for the student to learn that the physician’s 

responsibility toward the patient does not stop at the end of the office visit or hospitalization but 

continues in collaboration with other professionals to ensure that the patient receives optimal care. 


Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should 

include: 

Ability to perform patient-centered interviewing to determine the patients’ needs and 

communicate about diagnostic and therapeutic plans, transitions of care, and end-of-life care. 

Ability to identify community resources for care and strategies for coordination of care. 

Health Information Portability and Accountability Act (HIPAA) training to promote patient 

privacy. 

Required introductory courses in interviewing/physical examination with emphasis on doctorpatient 

communication and health care delivery. 



1. The role of consultants and their limits in the care of a patient. (MK, SBP) 

2. Key personnel and programs in and out of the hospital that may be able to contribute to the 

ongoing care of an individual patient for whom the student has responsibility (e.g. home health 

providers, social workers, case coordinators/managers, community health organizations, etc.). 

(MK, SBP) 

3. The role of the primary care physician in coordinating the comprehensive and longitudinal 

patient care plan, including communicating with the patient and family (directly, telephone, or 

email) and evaluating patient well-being through home health and other care providers. (MK, 

SBP) 

4. HIPAA guidelines to promote patient privacy. (MK, SBP) 

5. The role of the primary care physician in the coordination of care during key transitions 

(e.g. outpatient to inpatient, inpatient to skilled nursing facility, inpatient to hospice, etc.). (MK, 

SBP) 

6. The role of clinical nurse specialists, nurse practitioners, physicians assistants, and other 

allied health professionals in co-managing patients in the outpatient and inpatient setting. (MK, 

SBP) 

7. The importance of reconciliation of medications at all transition points of patient care. (MK, 

SBP) 

8. The rationale for a standardized approach to all “hand off” communications (MK, SBP) 


1. Discussing with the patient and their family ongoing health care needs; using appropriate 

language, avoiding jargon, and medical terminology. (PC, CS) 

215

2. Participating in requesting a consultation and identifying the specific question to be 

addressed. (PC, CS, .SBP) 

3. Participating in the discussion of the consultant’s recommendations. (PC, CS, SBP) 

4. Participating in developing a coordinated, ongoing care plan in the community. (PC, SBP) 

5. Obtaining a social history that identifies potential limitations in the home setting which may 

require an alteration in the medical care plan to protect the patient’s welfare. (PC, CS) 

6. Reconciling patient medications at key transition points in care. (PC, SBP) 

7. Conveying accurately vital patient information at all care “hand-off” points (PC, CS, SBP) 


1. Demonstrate teamwork and respect toward all members of the health care team. (P, SBP) 

2. Demonstrate responsibility for patients’ overall welfare. (P) 

3. Participate, whenever possible, in coordination of care and in the provision of continuity. (P, 

SBP) 


Goldman L, Lee, T, Rudd P. Ten commandments of effective consultation. Arch Intern Med. 

1983;143:1753-5. 

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across diseases, settings, 

and clinicians: a key role for the generalist in practice. Ann Intern Med. 2005;142:700-708. 

Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: 

a multidisciplinary review. BMJ. 2003;327:1219-21. 

Wenger NS, Young R. Quality indicators of continuity and coordination of care for vulnerable 

elder persons. Rand Corporation, 2004. 

www.rand.org/pubs/working_papers/2004/RAND_WR176.pdf 

Building a Case for Medication Reconciliation Institute for Safe Medication Practices 

www.ismp.org/Newsletters/acutecare/articles/20050421.asp 

Reconcile Medications at All Transition Points Institute for Healthcare Improvement 

www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Reco 

ncile+Medications+at+All+Transition+Points.htm 

Healthcare Communications Toolkit to Improve Transitions of Care Department of Defense 

Patient Safety Program 

https://patientsafety.satx.disa.mil/ ContentStore/2005_12- 

8%20Handoff%20Toolkit%20FINAL.htm 

216


#11 GERIATRIC CARE 

RATIONALE: 

Geriatric patients often have multiple, chronic illnesses which may present with atypical symptoms. 

Management strategies need to take into account the effects of aging on multiple organ systems and 

socioeconomic factors faced by our elderly society. As the number of geriatrics patients steadily 

rises, the internist will devote more time to the care of these patients. 


Required courses in anatomy, physiology, pathophysiology, physical examination, and nutrition 

with attention to specific considerations in the elderly. 





1. Functional implications of aging on each major organ system. (MK) 

2. Nutritional needs of the elderly and adaptations needed in the presence of chronic illness. 

(MK) 

3. Key illnesses in the elderly, focusing on their often atypical presentation, including: 

Cardiovascular and cerebrovascular disease. (MK) 

Diabetes. (MK) 

Urinary tract infection. (MK) 


Substance abuse. (MK) 

Depression. (MK) 

Thyroid disease. (MK) 

Fluid and electrolyte disturbances. (MK) 

Arthritis. (MK) 

Constipation. (MK) 

Acute abdomen. (MK) 

Depression. (MK) 

4. The common “geriatric syndromes” (i.e. symptoms and conditions common in the elderly and 

often multifactorial in origin), including: 

Immobility. (MK) 

Falls/gait and balance problems. ( MK) 

Dizziness. (MK) 

Incontinence. (MK) 

Weight loss/failure to thrive/malnutrition. (MK) 

Sleep disturbance. (MK) 

Dementia/delirium. (MK) 

Osteoporosis. (MK) 

Hearing and visual impairment. (MK) 

Pressure ulcers. (MK) 

217

5. Basic treatment plans for illness in the elderly, with an awareness of the pharmacokinetic and 

pharmacodynamic changes seen as we age. (MK) 

6. Principles of screening in the elderly, including immunizations, cardiovascular risk, cancer, 

substance abuse, mental illness, osteoporosis, and functional assessment. (MK) 

7. Factors that contribute to polypharmacy in the elderly. (MK) 

8. Principles of Medicare (including who and what services are covered) and prescription drug 

coverage (who and what drugs are covered). (MK, SBP) 


1. Taking a complete and focused history from a geriatric patient with attention to current 

symptoms, chronic illnesses, and physical and mental functioning (PC, CS) 

2. Always obtaining historical information from collateral source, whenever possible. (PC, CS) 

3. Performing a physical examination and functional assessment on an elderly patient, adapting it 

to a patient's symptoms, chronic illness, and possible conditions of frailty, immobility, hearing 

loss, memory loss, and other impairments. (PC) 

4. Performing a mental status examination to evaluate confusion and/or memory loss in an 

elderly patient. (PC) 

5. Identifying patients at high risk for falling. (PC) 

6. Developing a diagnostic and management plan for patients with the with symptoms/conditions 

common in the geriatric population. (PC, MK) 

7. Communicating the diagnosis, treatment plan, and subsequent follow-up to the patient and 

their family. (PC, CS) 

8. Eliciting input and questions from the patient and their family about the diagnostic and 

management plan. (PC, CS) 

9. With guidance and direct supervision, participating in discussing basic issues regarding 

advance directives with patients and their families. (CS) 

10. With guidance and direct supervision participating in discussing basic end-of-life issues with 

patients and their families. (CS) 

11. Actively attempting to limit polypharmacy whenever possible. (PC) 

12. Participating in an interdisciplinary approach to management and rehabilitation of elderly 

patients. (PC, SBP) 

13. Determine when to obtain consultation from a geriatric specialist. (PC, SBP) 

14. Accessing and using appropriate information systems and resources to help delineate issues 

related to the common geriatric syndromes. (PC, PLI) 

15. Incorporating patient needs and preferences. (PC, P) 


1. Respect the increased risk for iatrogenic complications among elderly patients by always 

taking into account risks and monitoring closely for complications (P) 

2. Demonstrate respect to older patients, particularly those with disabilities, by making efforts to 

preserve their dignity and modesty. (P) 

3. Always treat cognitively impaired patients and patients at the end of their lives with utmost 

respect and dignity. (P) 


considerations in the selection of diagnostic and therapeutic interventions for the common 

geriatric syndromes. (PLI, P) 


and therapeutic options for the common geriatric syndromes. (P) 

218

6. Demonstrate ongoing commitment to self-directed learning regarding care of the geriatric 

patient. (P, PLI) 

7. Appreciate the impact the common geriatric syndromes have on a patient’s quality of life, wellbeing, 



care professionals in the diagnosis and treatment of geriatric patients. (P, SBP) 


The American Geriatrics Society 

www.americangeriatrics.org/ 

Guidelines and Position Statements 

www.americangeriatrics.org/products/positionpapers/ 

Portal of Geriatric Online Education (POGOe) 

In association with AAMC MedEdPORTAL 

www.pogoe.org 

Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 

2003;348(1):42-9. 

Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61:2159-68, 2173-4 

Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic approach to 

maintaining health. Am Fam Physician. 2000;61:1089-104. 

Willlams CM. Using medications appropriately in older adults. Am Fam Physician. 

2002;66:1917-24. 

Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam 

Physician. 2002;65:640-50. 

Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science. Ann Intern 

Med. 2001;134:823-32. 

Cummings JL. Alzheimer's disease. N Engl J Med. 2004;351:56-67. 

Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003;349:1360-8. 

Resnick NM, Dosa D. Geriatric medicine. In Kasper DL, Braunwald EB, Fauci AS, Hauser SL, 

Longo DL, Jameson JL eds. Harrison’s Principles of Internal Medicine. 16th ed. New York, 

NY: McGraw-Hill; 2005:43-53. 

219

#12 BASIC PROCEDURES 


RATIONALE: 

For many students, the internal medicine clerkship is where the basic procedural skills required in 

other clerkships, subinternships, and residencies are learned. 



Pertinent anatomic considerations, including venous anatomy of the extremities (for 

venipuncture and IV placement), arterial anatomy of the wrist and groin (for blood gases), 

vaginal/vulvar anatomy (for urethral catheterization in women as well as pap smear) and 

prostate anatomy in men (for prostate exam), rectal anatomy (for digital rectal exam) and 

surface anatomy and electrical vector orientation of the heart (for EKG placement). 

The fundamental tenants of informed consent. 

Basic training in body substance isolation procedures and sterile technique. 



1. Key indications, contraindications, risks to patients and health care providers, benefits, and 

techniques for each of the following basic procedures: 

Venipuncture. (MK) 

Blood culture. (MK) 

ABG. (MK) 

ECG. (MK) 

Chest radiography. (MK) 

Nasogastric tube placement. (MK) 

Urethral catheterization. (MK) 

Peripheral intravenous catheter insertion. (MK) 

Throat culture. (MK) 

PAP smear. (MK) 

Digital rectal examination. (MK) 

Urine dipstick. (MK) 

Stool occult blood testing. (MK) 

Subcutaneous injection. (MK) 

Intramuscular injection. (MK) 

Wound culture. (MK) 

Dressing change. (MK) 

PPD placement. (MK) 

2. Alternatives to a given procedure. (MK) 

3. The patient’s experience of the procedure. (MK) 


220

1. Obtaining informed consent, when necessary, for basic procedures, including the explanation 

of the purpose, possible complications, alternative approaches, and conditions necessary to 

make the procedure as comfortable, safe, and interpretable as possible. (PC, CS) 

2. Explaining what the patient’s experience is likely to be in understandable terms. (CS) 

3. Demonstrating step-by-step performance of basic procedures with technical proficiency. (PC) 

4. Demonstrating proper sterile technique and body substance isolation procedures. (PC) 

5. Appropriately documenting, when required, how the procedure was done, any complications, 

and results. (CS) 


1. Appreciate the fear and anxiety many patients have regarding even simple procedures. (P) 

2. Make efforts to maximize patient comfort during a procedure. (P) 

3. Appreciate the patient’s right to refuse procedures. (P) 

4. Regularly seek feedback regarding procedural skills and respond appropriately and 



Guide to procedures. In Lin GA, Lin TL, Sakurai KA, De Fer TM, eds. The Washington Manual 

Internship Survival Guide. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005:178- 

210. 

Chen H, Sonneday CJ, Lillemoe KD eds. Manual of Common Bedside Surgical Procedures. 

2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2000. 

Ferri FF. Procedures and interpretation of results. In Ferri FF, ed. Practical Guide to the Care 

of the Medical Patient. 6th ed. St. Louis, MO: Mosby; 2004:903-934. 

221


#13 NUTRITION 

RATIONALE: 

Despite the importance of nutritional factors in health and illness, physicians frequently have been 

criticized for giving these factors inadequate attention. Internists, by virtue of their dedication to 

providing comprehensive care to their patients, must assess nutritional factors on a routine basis. 

Medical students should be prepared to provide patients with basic advice regarding ways to optimize 

their nutritional status. Students also need to have at least a basic working knowledge of the 

principles of nutritional assessment and intervention. 



Ability to perform a complete medical history. 


Knowledge of body metabolism, the respective roles of dietary fats, carbohydrates, and 

protein, and the need for vitamins and minerals for maintenance of health. 


A. KNOWLEDGE: Each student should be able to define, describe, and discuss: 

1. The relationship between diet and disease. (MK) 

2. Common medical problems that can cause nutritional deficiencies. (MK) 

3. Contributions of nutrition to medical problems such as obesity, 

hyperlipidemia, diabetes, and hypertension. (MK) 

4. How to perform a nutritional assessment and assist the patient in setting goals for dietary 

improvement. (MK) 

5. Daily caloric, fat, carbohydrate, protein, mineral, and vitamin requirements; adequacy of diets 

in providing such requirements; evidence of need for and potential risks of supplements (e.g. 

calcium, antioxidants). (MK) 

6. Common dietary supplements and their known adverse and beneficial effects on health. (MK) 

7. The consequences of poor nutrition on a critically ill patient, such as poor wound healing, 

increased risk of infection, and increased mortality. (MK) 

8. Nutritional needs of the elderly and adaptations needed in the presence of chronic illness. 

(MK) 

9. The indications for enteral and parenteral nutrition. (MK) 

B. SKILLS: Student should be able to demonstrate specific skills, including: 

1. Obtaining a nutritional history for all patients, with additional focus on those with chronic 

disease (obesity, hyperlipidemia, diabetes mellitus, hypertension, alcoholism, cancer, COPD, 

CHF, renal, and GI disease), giving attention to weight change, appetite, eating habits, 

digestive problems, dental problems, physical handicaps, psychiatric problems, socioeconomic 

factors, alcohol use, medications, and physical activity. (PC, CS) 

2. Identifying physical exam abnormalities that may suggest malnutrition, such as muscle 

wasting, decreased adipose stores, as well as stigmata of vitamin/mineral or protein-calorie 

222

malnutrition (e.g. alopecia, ecchymoses, angular chelosis, glossitis, peripheral neuropathy, 

edema, etc.). (PC) 

3. Calculating a patient’s body mass index (BMI) and measuring waist circumference. (PC) 

4. Ordering appropriate tests for evaluating a patient’s nutritional status, including albumin, 

prealbumin, serum chemistries and coagulation profile(PC) 

5. Performing basic nutritional counseling with patients with obesity, diabetes mellitus, 

hyperlipidemia, hypertension, heart failure, and coronary artery disease. (PC, CS) 

6. Identifying barriers that prevent a patient from successfully adhering to a recommended diet. 

(PC, CS) 

7. Determining when to obtain consultation from a dietician. (PC, SBP) 

8. Incorporating patient needs and preferences. (PC, P) 



considerations in the selection of diagnostic and therapeutic interventions for malnutrition. (PLI, 

P) 

2. Recognize the importance of patient preferences and cultural factors when selecting nutritional 

counseling. (PLI, P) 

3. Respond to patients who are non-adherent to recommendations for appropriate nutritional 

intake. (CS, P) 

4. Demonstrate ongoing commitment to self-directed learning regarding nutrition. (PLI, P) 

5. Appreciate the impact malnutrition has on a patient’s quality of life, wellbeing, ability to work, 


6. Recognize the importance of involving other healthcare professionals when appropriate. (P, 

SBP) 


Division of Nutrition and Physical Activity National Center for Chronic Disease Prevention and 

Health Promotion 


U.S. Department of Health and Human Serviced 

www.cdc.gov/nccdphp/dnpa/ 

Dietary Guidelines for Americans 

U.S. Department of Agriculture 


www.health.gov/dietaryguidelines/ 

American Dietetic Association 

www.eatrigh.org 

Food and Nutrition Information Center 

U.S. Department of Agriculture 

www.nal.usda.gov/fnic/ 

Dwyer J. Nutritional requirements and dietary assessment. In Kasper DL, Braunwald EB, 

Fauci AS, Hauser SL, Longo DL, Jameson JL eds. Harrison’s Principles of Internal Medicine. 

16th ed. New York, NY: McGraw-Hill; 2005:399-403. 

Halsted CH. Malnutrition and nutritional assessment. In Kasper DL, Braunwald EB, Fauci AS, 

Hauser SL, Longo DL, Jameson JL eds. Harrison’s Principles of Internal Medicine. 16th ed. 


Howard L. Enteral and parenteral nutrition therapy. In Kasper DL, Braunwald EB, Fauci AS, 

223

Hauser SL, Longo DL, Jameson JL eds. Harrison’s Principles of Internal Medicine. 16th ed. 


224

#14 COMMUNITY HEALTH CARE 


RATIONALE: 

The increasing number of physicians practicing under managed care and in community-oriented 

primary care practices necessitates expanding medical education to prepare graduates for 

population-based clinical practice. In a managed care setting, population-based clinical practice 

includes the health of an enrolled population. In a community-based setting, population-based clinical 

practice includes the health of a population in addition to the health of the individual patient through 

concern with resource allocation, epidemiology, and the care of patients whose needs are not 

currently met by the health care system. 



include: 

Required introductory coursework in health care delivery (with an emphasis on medical 

sociology and health care delivery to at risk populations). 

Required introductory course in clinical epidemiology and biostatistics. 

Required introductory coursework in population health (with an emphasis on differences 

between individuals and populations). 



1. The concepts of rate, incidence, and prevalence to characterize the health of a population. 

(MK) 

2. How to gather health information about a population. (MK) 

3. How disease epidemiology in a community differs from that experienced in an office or hospital 

practice. (MK) 

4. How health care financing and health care delivery systems affect individual physicians, 

patients, and communities. (MK, SBP) 

5. How community and individual responses to health problems may be affected by both 

individual and community socio-cultural characteristics. (MK) 

6. Local government, social service, or community organizations that provide links between the 

underserved members of the community and the medical care systems. (MK, SBP) 

7. barriers faced by his or her patients in the community setting. (MK) 


1. Defining and describing a population, its demography, culture, socioeconomic makeup, and 

health status. (PC) 

2. Identifying the unique characteristics of a population that affect the health of the population and 

individuals within that population. (PC) 

3. Considering how the socio-cultural characteristics of a particular community may affect that 

population’s attitudes toward health care. (PC) 

4. Using, in daily patient care, an understanding of the community and sociocultural context that 

may affect an individual patient’s health care decisions and health-related behaviors. (PC) 

225

5. Identifying patients whose illnesses may put the community at risk. (PC, MK) 

6. Incorporating a population-based perspective in analyzing clinical problems (PC) 

7. Reading critically clinical studies and applying findings to health care decisions involving real 

patients and populations of patients. (PC, MK, PLI) 

8. Incorporating principles of disease prevention and behavioral change appropriate for specific 

populations of patients within a community. (PC, MK) 

9. Attempting to develop solutions for barriers to health care delivery (e.g. sociocultural, financial, 

and system-based) that affect individual patients. (PC, SBP) 

10. Functioning effectively as a member of a health care team. (PC, P, SBP) 

11. Using, when appropriate, local government, social service, and community organizations to 

improve the health of individuals and populations. (PC, SBP) 

12. Accessing and utilizing appropriate information systems and resources to help delineate issues 

related to population health. (PC, PLI) 


1. Demonstrate respect for cultural and socioeconomic diversity. (P) 

2. Show willingness to accept at least partial responsibility for the health of populations. (P) 

3. Respond non-judgmentally to an individual whose socio-cultural and community-based 

background result in seemingly counterproductive heath care decisions and health-related 

behaviors. (P) 

4. Value the unique contributions of all members of the health care team. (P) 

5. Demonstrate ongoing commitment to self-directed learning regarding population/community 

health issues. (PLI, P) 


Contemporary Issues in Medical Education: Quality of Care 

Medical Informatics and Population Health, June, 1998 

American Association of Medical Colleges 

www.aamc.org/meded/msop/msop2.pdf 

Population Health Forum 

University of Washington 

School of Public Health and Community Medicine 

depts.washington.edu/eqhlth/index.htm 

Behavioral Risk Factor Surveillance System Division of Adult and Community Health National 

Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and 

Prevention 


www.cdc.gov/brfss/index.htm 

Healthy People 2010 National Center for Health Statistics 



www.cdc.gov/nchs/hphome.htm 

Rhyne RL, Bogue R, Kukulka G, Fulmer H, eds. Community-Oriented Primary Care: Health 

Care for the 21st Century. Washington, DC: American Public Health Association; 1998. 

Strelnick AH. Community-oriented primary care: the state of an art. Arch Fam Med. 

1999;8:550-2. 

Fox DM. The relevance of population health to academic medicine. Acad Med. 2001;76:6-7. 

Kindig D, Stoddart G. What is population health?. Am J Public Health. 2003;93:380-3. 

226


#15 CONTINUOUS IMPROVEMENT IN SYSTEMS OF MEDICAL PRACTICE 

RATIONALE: 

In the past clinical education had emphasized the role of the physician as an individual decision 

maker. Problems with cost and quality of care had usually been attributed to errors in individual 

decision making. In recent years, it has become clear that the individual does not function in isolation 

but within the context of a health care system and a health care team whose structure ranges from 

simple to complex. The way the system functions is critical to achieving high quality patient care, 

ensuring patient safety, reducing sources of errors in medicine, and promoting an environment that 

respects disclosure without blame. Furthermore, we have begun to focus on the patient as the center 

of the health care delivery system and to assess quality from the perspectives of the patient and the 

physician. With the patient as the center of the health care delivery system, the physician becomes a 

collaborative partner with other health professionals who share a common goal of providing safe, 

accessible, high quality, evidence-based care. 



Required introductory course in clinical epidemiology and biostatistics. 

Required introductory course in health care delivery. 

Required introductory course in bioethics and professionalism. 



1. The concept of systems-based practice. (MK, SBP) 

2. How patient care is affected by other professionals, organizations, and society. (MK, SBP) 

3. The principles of clinical quality improvement, including the notion of variation in practice as a 

quality issue and the concept of medical care as a process which can be studied and 

improved. (MK, SBP) 

4. The analysis and improvement of systems to address common quality problems (e.g., 

treatment delays, medication errors, failure to use evidence-based diagnostics/treatments, 

failure to provide preventive care, etc.). (MK, SBP) 

5. Principles of medical record organization in both inpatient and ambulatory settings. (MK, SBP) 

6. The importance of complete medical documentation in the context of measuring quality of 

care, avoiding redundancy, preventing medical errors, and improving patient safety. (MK, SBP) 

7. The need for a multidimensional approach to the assessment of quality, including the patient’s 

perspective of quality. (MK, SBP) 

8. The relationship of quality and cost in health care from the standpoint of the individual, health 

care systems, and society. (MK, SBP) 

9. Major health care safety concerns (e.g., medication errors, wrong-site procedures, patient 

misidentification, miscommunication among health care givers, nosocomial infections, falls, 

use of restraints, etc.). (MK, SBP) 

10. Potential benefits and pitfalls of critical pathways/practice guidelines intended to improve the 

quality of care. (MK, SBP) 

11. Basic organizational structures and financing streams of the U.S. health care system. (MK, 

SBP) 

227

12. The fundamentals of the various type of health insurance (e.g., fee-for-service, preferred 

provider organization, health maintenance organization, point-ofservice). (MK, SBP) 

13. The fundamentals of Medicare and Medicaid. (MK, SBP) 


1. Using hospital-based support systems to assist in making clinical decisions (e.g., antibiotic 

control program, critical pathways/practice guidelines, etc.). (PC, PLI, SBP) 

2. Recognizing system flaws in the delivery of care (e.g., inability to arrange a post-discharge 

appointment within a needed time frame, delays in obtaining test results, inaccessibility of 

medical records, etc.). (SBP) 

3. Using patient education materials to facilitate patients’ participation in their own care. (CS, 

SBP) 

4. Using the medical records system efficiently to produce medical notes that communicate 

information clearly. (PC, CS, SBP) 

5. Maintaining accurate documentation of preventive health measures. (PC, CS, SBP) 

6. Working collaboratively with other health professionals in the delivery of quality care. (PC, P, 

SBP) 

7. Assessing the patients’ needs from the standpoint of the individual, family, and community. 

(PC, SBP) 

8. Identifying resource available to patients within the health care system. (PC, SBP) 

9. Reporting patient safety concerns and medical errors to the appropriate individuals. (CS, SBP) 

10. Using resources, appropriate information systems, and the tenants of evidence-based 

medicine to assess systems-based practice issues. (PLI, SBP) 


1. Recognize the importance of systems, particularly inter-professional collaboration, in delivering 

high quality patient care. (P, SBP) 

2. Strive to improve the timeliness diagnostic and therapeutic decision making in order to improve 

quality of care, increase patient satisfaction, and reduce health care costs. (PLI, P, SBP) 

3. View the patient as the center of the health care delivery system. (P, SBP) 

4. Advocate for patients in the health care system. (P, SBP) 

5. Appreciate that medical error prevention and patient safety are the responsibility of all health 

care providers and systems and accept the appropriate degree of responsibility at the medical 

student level. (P, SBP) 

6. Appreciate the importance teamwork in delivering high quality care. (P, SBP) 

7. Respect other health care professionals as colleagues on a patient-centered health delivery 

team and as mutual contributors to high quality patient care. (P, SBP) 


GENERAL: 



ahrq.gov 

QUALITY OF CARE: 

Institute for Healthcare Improvement 

228

www.ihi.org/ihi 

Crossing the Quality Chasm: A New Health System for the 21st Century 

Committee on Quality Health Care in America 

Institute of Medicine 

National Academies Press, 2001 

National Committee for Quality Assurance 

www.ncqa.org 

National Guideline Clearing House 



www.guideline.gov 

MEDIAL ERRORS AND PATIENT SAFETY: 

To Err Is Human: Building a Safer Health System 

Institute of Medicine 

www.iom.edu/?id=4117&redirect=0 

Patient Safety Network 



psnet.ahrq.gov 

National Patient Safety Foundation 

www.npsf.org 

Facts About Patient Safety 

Joint Commission on Accreditation of Healthcare Organizations 

www.jcaho.org/accredited+organizations/patient+safety/facts+about+pati 

ent+safety.htm 

HEALTH INSURANCE AND FINANCE: 

Understanding Managed Care 

Institute for Health Care Studies 

Michigan State University 

www.ihcs.msu.edu/modules/UMC2003/UMC2003.pdf 

The Official U.S. Government Site for People with Medicare 


www.medicare.gov 

Checkup on Health Insurance Choices 


www.ahrq.gov/consumer/insuranc.htm 

229

#16 OCCUPATIONAL HEALTH CARE 


RATIONALE: 

Despite increasing recognition of the health hazards found in living and working environments, 

physicians have traditionally received little formal training in the assessment and management of 

occupational and environmental health problems. 



include: 

Required introductory course work in clinical epidemiology and biostatistics. 

Required introductory course work in the fundamental principles of public health. 




A. KNOWLEDGE: Each student should be able to define, describe, and discuss : 

1. Common environmental diseases that are likely to be encountered by an internist and the 

principal etiologic agents associated with them. (MK) 

2. Pathogenesis of specific occupational diseases and the types of risks that may be encountered 

in the home or at the work site: 

Musculoskeletal/ergonomic or “repetitive stress” disorders (e.g. low back pain, carpal 

tunnel syndrome, etc.). (MK) 

Work related lung disorders (e.g. occupational asthma, particulate inhalation, etc.). (MK) 

Noise related hearing loss. (MK) 

Skin disorders (e.g. latex allergy and other forms of occupational dermatitis). (MK) 

Infectious disease exposure (e.g. hepatitis, HIV, TB, etc.). (MK) 

Psychological/stress related disorders (MK) 

3. Information sources for determining the risk of specific environmental and occupational health 

hazards. (MK) 

4. Purpose of Occupational Safety and Health Act (OSHA) regulations and the function of the 

National Institute for Occupational Safety and Health. (NIOSH). (MK, SBP) 


1. Obtaining an appropriate occupational history on all patients and identifying those patients 

whose health may have been adversely affected by their living conditions or work environment. 

(PC, CS) 

2. Considering the possibility that the patient’s illness may be related to their home or work 

environment. (PC) 

3. Providing patients with sound advice on the prevention of occupational and environmentalrelated 

diseases. (PC, CS) 

4. Accurately diagnosing and developing a cost-effective basic management plan for common 

occupational health problems (e.g. carpal tunnel syndrome, asthma, asbestosis). (PC, MK, 

SBP) 

230

5. Determining when to obtain consultation from an environmental and occupational medicine 

specialist. (PC, SBP) 

6. Accessing and utilizing appropriate information systems and resources to help delineate issues 

related to occupational health problems. (PC, PLI) 


1. Demonstrate an understanding that physicians have a duty and professional responsibility to 

follow-up on conditions that are suspected of causing occupational or environmental-related 

illnesses. (P, SBP) 


considerations in the selection of diagnostic and therapeutic interventions for occupational 

health problems. (PLI, P) 


and therapeutic options for occupational health problems. (P) 

4. Demonstrate ongoing commitment to self-directed learning regarding occupational health 

problems. (PLI, P) 

5. Appreciate the impact occupational health problems have on a patient’s quality of life, wellbeing, 



care professionals in the diagnosis and treatment of occupational health problems. (P, SBP) 


Occupational Safety and Health Administration 

U.S. Department of Labor 

www.osha.gov 

National Institute for Occupational Safety and Health 



www.cdc.gov/niosh/homepage.html 

231

#17 ADVANCED PROCEDURES 


RATIONALE: 

A number of advanced procedures may be performed by general internists, and occasionally thirdyear 

medical students under their supervision. In either case, knowledge of the key indications, 

contraindications, risks, and benefits of these procedures is essential for high quality patient care. 

Physicians, regardless of specialty, must be able to explain to their patients, in understandable terms, 

what will be experienced during a procedure. 



Pertinent anatomic considerations, including vascular anatomy of the extremities, wrist/hand, 

neck, subclavian area and groin. 

Pertinent anatomic landmarks important for the safe performance of thoracentesis, 

paracentesis, lumbar puncture, and arthrocentesis. 

Required introductory course in interviewing and physical examination. 

The fundamental tenants of informed consent. 

Basic training in body substance isolation procedures and sterile technique. 



1. Key indications, contraindications, risks, benefits, techniques of each of the following advanced 

procedures: 

Arthrocentesis. (MK) 

o Elbow (olecranon bursa). (MK) 

o Wrist. (MK) 

o Knee. (MK) 

o Ankle. (MK) 

Central venous catheterization. (MK) 

o Internal jugular vein. (MK) 

o Subclavian vein. (MK) 

o Femoral vein. (MK) 

Arterial line placement. (MK) 

o Radial artery. (MK) 

o Femoral artery. (MK) 

Lumbar puncture. (MK) 

Thoracentesis. (MK) 

Paracentesis. (MK) 

2. Potential alternatives to the listed procedures. (MK) 

3. The patient’s probable experience during these procedures. (MK) 

4. Indications for and efficacy of intra-articular corticosteroid injections. (MK) 

B. SKILLS: Each student should be able to demonstrate specific skills, including: 

232

1. Participating in obtaining informed consent for advanced procedures, including the explanation 

of the purpose, possible complications, alternative approaches, and conditions necessary to 

make the procedure as comfortable, safe, and interpretable as possible. (PC, CS) 

2. Explaining the patient’s probable experience during the procedure in understandable terms. 

(PC, CS) 

3. Helping to position the patient and make them as comfortable as possible during the 

procedure. (PC) 

4. Assisting (under supervision, when appropriate) in the performance of the procedure. (PC) 

5. Demonstrating proper sterile technique and body substance isolation procedures. (PC) 

6. Appropriately documenting, when required, how the procedure was done as well as any 

complications and results. (CS) 

7. Ordering and interpreting appropriate diagnostic tests on fluids removed from the patient (e.g. 

synovial fluid, cerebrospinal fluid, pleural fluid, and ascitic fluid). (PC, MK) 

C. ATTITUDES AND PROFESSIONAL BEHAVIOR: Students should be able to: 


considerations in the selection of procedures to be performed. (PLI, P) 

2. Appreciate the fear and anxiety many patients have regarding these procedures. (P) 

3. Make efforts to maximize patient comfort during a procedure. (P) 

4. Appreciate the patient’s right to refuse procedures. (P) 

5. Seek feedback regularly regarding procedural skills and respond appropriately and 



Guide to procedures. In Lin GA, Lin TL, Sakurai KA, De Fer TM, eds. The Washington Manual 

Internship Survival Guide. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005:178- 

210. 

Chen H, Sonneday CJ, Lillemoe KD eds. Manual of Common Bedside Surgical Procedures. 

2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2000. 

Ferri FF. Procedures and interpretation of results. In Ferri FF, ed. Practical Guide to the Care 

of the Medical Patient. 6th ed. St. Louis, MO: Mosby; 2004:903-934. 

233

LIST OF ERROR-PRONE ABBREVIATIONS, SYMBOLS, AND DOSE 

DESIGNATIONS 

234

November 27, 2003 Volume 8 Issue 24 

ISMP List of Error-Prone Abbreviations, Symbols, and 

Dose Designations 

It’s been over 2 years since we published a list of abbreviations, symbols, the organization’s list, we’ve highlighted these items with a 

double and dose designations that have contributed to medication errors. Now, asterisk (**). Also, effective April 1, 2004, each 

organization must include with the 2004 JCAHO National Patient Safety Goals calling for organiza-at least three additional items on 

their list. However, we hope that you tional compliance with a list of prohibited “dangerous” abbreviations, will consider others 

beyond the minimum JCAHO requirement. Selections acronyms and symbols, we thought an updated list would be useful. can be 

made from the attached list. These items should be considered Since JCAHO has specified that certain abbreviations must appear on 

for handwritten, preprinted, and electronic forms of communication. 

Abbreviations Intended Meaning Misinterpretation Correction 

µg Microgram Mistaken as “mg” Use “mcg” 

AD, AS, AU 

Right ear, left ear, each Mistaken as OD, OS, OU (right eye, left eye, each Use “right ear,” “left ear,” or 

ear 

eye) 

“each ear” 

OD, OS, OU 

Right eye, left eye, each Mistaken as AD, AS, AU (right ear, left ear, each Use “right eye,” “left eye,” or 

eye 

ear) 

“each eye” 

BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime” 

cc Cubic centimeters Mistaken as “u” (units) Use “mL” 

D/C Discharge or 

discontinue 

Premature discontinuation of medications if D/C 

(intended to mean “discharge”) has been 

misinterpreted as “discontinued” when followed by 

a list of discharge medications 

235 

Use “discharge” and 

“discontinue” 

IJ Injection Mistaken as “IV” or “intrajugular” Use “injection” 

IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” 

HS hs Half-strength At Mistaken as bedtime Mistaken as half-strength Use “half-strength” or “bedtime” 

bedtime, hours of sleep 

IU** International unit Mistaken as IV (intravenous) or 10 (ten) Use “units” 

o.d. or OD Once daily Mistaken as “right eye” (OD-oculus dexter), leading Use “daily” 

to oral liquid medications administered in the eye 

OJ Orange juice Mistaken as OD or OS (right or left eye); drugs Use "orange juice" 

meant to be diluted in orange juice may be given in 

the eye 

Per os By mouth, orally 

The “os” can be mistaken as “left eye” (OS-oculus Use “PO,” “by mouth,” or 

sinister) 

“orally” 

q.d. or QD** Every day Mistaken as q.i.d., especially if the period after the Use “daily” 

“q” or the tail of the “q” is misunderstood as an “i” 

qhs At bedtime Mistaken as “qhr” or every hour Use “at bedtime” 

qn Nightly Mistaken as “qh” (every hour) Use “nightly” 

q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d. (four times Use “every other day” 

daily) if the “o” is poorly written 

q1d Daily Mistaken as q.i.d. (four times daily) Use “daily” 

q6PM, etc. Every evening at 6 PM Mistaken as every 6 hours 

Use “6 PM nightly” or “6 PM 

daily” 

SC, SQ, sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 

every;” the “q” in “sub q” has been mistaken as 

Use “subcut” or 

“subcutaneously” 

“every” (e.g., a heparin dose ordered “sub q 2 hours 

before surgery” misunderstood as every 2 hours 

before surgery) 

ss Sliding scale (insulin) or 

½ (apothecary) 

Mistaken as “55” 

Spell out “sliding scale;” use 

“one-half” or “½” 

SSRI SSI 

Sliding scale regular 

insulin Sliding scale 

insulin 

Mistaken as selective-serotonin reuptake inhibitor 

Mistaken as Strong Solution of Iodine (Lugol's) 

Spell out “sliding scale (insulin)” 

i/d One daily Mistaken as “tid” Use “1 daily” 

TIW or tiw 3 times a week Mistaken as “3 times a day” or “twice in a week” Use “3 times weekly”

U or u** Unit Mistaken as the number 0 or 4, causing a 10-fold Use “unit” 

overdose or greater (e.g., 4U seen as “40” or 4u seen 

as “44”); mistaken as “cc” so dose given in volume 

instead of units (e.g., 4u seen as 4cc) 

Dose Designations 

and Other 

Information 

Intended Meaning Misinterpretation Correction 

Trailing zero 

after decimal 

point (e.g., 1.0 

mg)** 

No leading zero 

before a decimal 

dose (e.g., .5 

mg)** 

1 mg Mistaken as 10 mg if the decimal point is not seen 

0.5 mg Mistaken as 5 mg if the decimal point is not seen 

Do not use trailing zeros for 

doses expressed in whole 

numbers 

Use zero before a decimal point 

when the dose is less than a 

whole unit 

_ ISMP 2003 

ISMP MedicationSafetyAlert! 

November 27, 2003 Volume 8 Issue 24 

Dose Designations Intended Meaning Misinterpretation Correction 

and Other Information 

Drug name and dose 

run together 

(especially 

Inderal 40 mg Tegretol 

300 mg 

Mistaken as Inderal 140 mg Mistaken as 

Tegretol 1300 mg 

Place adequate space between the 

drug name, dose, and unit of 

measure 

problematic for drug 

names that end in 

“L” such as 

Inderal40 mg; 

Tegretol300 mg) 

Numerical dose and 

The “m” is sometimes mistaken as a zero or Place adequate space between the 

unit of measure run 

two zeros, risking a 10- to 100-fold overdose dose and unit of measure 

10 mg 100 mL 

together (e.g., 10mg, 

100mL) 

Abbreviations such 

The period is unnecessary and could be Use mg, mL, etc. without a 

as mg. or mL. with a 

mistaken as the number 1 if written poorly terminal period 

mg mL 

period following the 

abbreviation 

Large doses without 

properly placed 

commas (e.g., 100000 

units; 1000000 units) 

100,000 units 1,000,000 

units 

100000 has been mistaken as 10,000 or 

1,000,000; 1000000 has been mistaken as 

100,000 

Use commas for dosing units at 

or above 1,000, or use words 

such as 100 "thousand" or 1 

"million" to improve readability 

Drug Name 

Abbreviations 

Intended Meaning Misinterpretation Correction 

ARA A vidarabine Mistaken as cytarabine (ARA C) Use complete drug name 

AZT zidovudine (Retrovir) Mistaken as azathioprine or aztreonam Use complete drug name 

CPZ 

Compazine 

(prochlorperazine) 

Mistaken as chlorpromazine 

Use complete drug name 

DPT 

Demerol-Phenergan- Mistaken as diphtheria-pertussis-tetanus 

Thorazine 

(vaccine) 


DTO Diluted tincture of opium, Mistaken as tincture of opium 


or deodorized tincture of 

opium (Paregoric) 

HCl hydrochloric acid or 

hydrochloride 

Mistaken as potassium chloride (The “H” is 

misinterpreted as “K”) 

Use complete drug name unless 

expressed as a salt of a drug 

HCT hydrocortisone Mistaken as hydrochlorothiazide Use complete drug name 

HCTZ hydrochlorothiazide 

Mistaken as hydrocortisone (seen as HCT250 

mg) 


MgSO4** magnesium sulfate Mistaken as morphine sulfate Use complete drug name 

MS, MSO4** morphine sulfate Mistaken as magnesium sulfate Use complete drug name 

MTX methotrexate Mistaken as mitoxantrone Use complete drug name 

PCA procainamide Mistaken as Patient Controlled Analgesia Use complete drug name 

236

PTU propylthiouracil Mistaken as mercaptopurine Use complete drug name 

T3 

Tylenol with codeine No. 

3 

Mistaken as liothyronine 


TAC triamcinolone Mistaken as tetracaine, Adrenalin, cocaine Use complete drug name 

TNK TNKase Mistaken as “TPA” Use complete drug name 

ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug name 

Stemmed Drug Names Intended Meaning Misinterpretation Correction 

“Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name 

“Norflox” norfloxacin Mistaken as Norflex Use complete drug name 

“IV Vanc” intravenous vancomycin Mistaken as Invanz Use complete drug name 

Symbols Intended Meaning Misinterpretation Correction 

Dram Minim 

Symbol for dram mistaken as “3” Symbol for Use the metric system 

minim mistaken as “mL” 

x3d For three days Mistaken as “3 doses” Use “for three days” 

> and < Greater than and less than Mistaken as opposite of intended; mistakenly Use “greater than” or “less than” 

use incorrect symbol; “< 10” mistaken as “40” 

/ (slash mark) Separates two doses or 

indicates “per” 

Mistaken as the number 1 (e.g., “25 units/10 

units” misread as “25 units and 110” units) 

Use “per” rather than a slash 

mark to separate doses 

@ At Mistaken as “2” Use “at” 

& And Mistaken as “2” Use “and” 

+ Plus or and Mistaken as “4” Use “and” 

° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr,” “h,” or “hour” 

_ ISMP 2003 

** Identified abbreviations above are also included on the JCAHO's "minimum list" of dangerous abbreviations, acronyms and symbols 

that must be included on an organization's "Do NotUse" list, effective January 1, 2004. An updated list of frequently asked questions 

about this JCAHO requirement can be found on their website at www.jcaho.org. 

ISMP MedicationSafetyAlert! 

237

COMPREHENSIVE WRITE-UPS 

Definition of Comprehensive Write-up 

A Comprehensive Write-up is a complete history and physical or a problem-focused note in 

standard Problem-Oriented Medical Record form (see following examples) and includes: 

a) a complete Problem List, with problems designated as “active” or 

“inactive/resolved” with dates of onset and resolution, respectively 

b) a comprehensive Assessment of at least three (3) problems from the Problem 

List, with discussion of differential diagnoses of undiagnosed problems (including rationale for 

including/excluding diagnoses) or discussion of diagnosed problems (such as course, 

complications, control and compliance) 

c) Plans, divided into Diagnostic, Therapeutic and Education Plans 

d) Resources and References 

e) Student’s name, printed and signed, followed by “MS3” 

f) Abbreviations: Since medical records communicate important information and 

may be scrutinized, abbreviations should not be used because their meaning is not universal 

among all readers of the medical records. Specifically, students should not use error-prone 

abbreviations, symbols, and dose designations (see Appendix). 

Submission Requirements of Comprehensive Write-ups 

a) 6B and 6L students on Inpatient Medicine are required to submit 3 write-ups by halfway 

through the inpatient rotation (averaging 1 write-up each week). The Hospital Site Coordinator 

will decide whether these 3 write-ups are satisfactory. If they are deemed satisfactory, then 

the student will not be required to submit any more write-ups. If, however, they are deemed 

unsatisfactory, then the student will be required to submit 1 – 3 additional write-ups, as 

determined by the Hospital Site Coordinator, up to a maximum of 6 write-ups. 

b) 6B students on Ambulatory Medicine are required to submit 2 write-ups each week for a 

total of 10 write-ups to their Ambulatory Preceptor. 

c) 6L students on Ambulatory Medicine are required to submit 2 write-ups each month for 

a total of 10 write-ups to their Ambulatory Preceptor. 

d) All write-ups, either originals with corrections/comments from the preceptor or copies of 

the originals with corrections/comments, must be turned in by the last day of the respective 

inpatient or ambulatory component of the clerkship. 

238

Example of Inpatient History and Physical 

Date of Admission: 11/01/02 

Date of Exam: 11/01/02 

ID: 78-yo Japanese woman who is a widow and a retired hotel worker 

S/R: Patient and her daughter, who are fair historians. Medical records not available. 

RE: Admission to Progressive Care Unit at Kuakini Medical Center 

CC: Three episodes of "Bloody stools" since last night 

HPI: The patient is a 78-year old woman with history of hypertension, hypercholesterolemia and two 

previous "mild strokes", who was in her usual state of health until October 29, 2002, three days prior 

to admission, when she began passing bright red blood per rectum along with "dark black clots" and 

"black stools", The patient claims to have had more than 10 bowel movements of this kind within 10 

hours. She admits to feeling weak at this time with a "near-fainting" episode after which she found 

herself drenched with sweat, as if "someone dumped a bucket of water over my head". The patient's 

daughter claims that the patient may have experienced a brief loss of consciousness (less than 30 

seconds.) during this "near-fainting" episode, as she stopped talking for a short period of time. On the 

morning of October 30, 2002, the patient went in to see her physician, Dr. Shozo Ogawa. At this time 

the bleeding had ceased and her only complaint was weakness. Dr. Ogawa found her to be stable, 

and found her hemoglobin to be 12.2, and arranged for her to follow-up with a gastroenterologist. On 

October 31 st , at around 5:00pm, the patient again began to pass bright red blood per rectum, but 

without black clots. She says she passed 3 bloody bowel movements since that time until she 

presented to the Emergency Room on the morning of November 1st. She admits to feeling weak and 

"lousy" and again feeling faint, but not actually fainting. 

The patient denies any prior episodes of rectal bleeding. She had experienced some constipation the 

week before, and had used Metamucil, which had given relief. She denies fever, nausea, vomiting, 

diarrhea, sick contacts, chest pain, shortness of breath, recent weight changes or changes in 

appetite. She claims to have a chronic mild right lower quadrant abdominal pain which she attributes 

to her degenerative vertebral disc disease. She also admits to having "sour stomach" every few 

months, but no history of previously diagnosed GERD or peptic ulcer disease. 

In 2000, the patient was diagnosed with "degenerative disc disease" in her lower spine. She claims to 

have had back pain since age 17, and utilizes a back brace and cane to assist in mobilization. She 

has been using aspirin for the pain, with her last dose taken 10 days ago. She was told by her 

physician at the office visit three days ago that "aspirin wasn't good for her stomach" and so she has 

since been taking Extra-Strength Tylenol, with gives her only partial relief. 

PMH: 

Childhood illnesses: Not asked 

Immunizations: Not asked 

Adult illnesses: Two "mild strokes" (Had slurred speech) in 1970s 

Cervical cancer – had possible cone biopsy in 1970s 

Hypertension- first aware of diagnosis in 1970s 

Degenerative disc disease- told of diagnosis in 2000; uses back brace, cane, occasional 

acupuncture 

Cataracts bilaterally- date of diagnosis unknown 

Hypercholesterolemia- date of diagnosis unknown 

The patient has no history of bleeding disorder, liver disease, diabetes mellitus, myocardial infarction 

or renal disease. 

Hospitalizations/Surgeries: 

1950s Kapiolani Medical Center- birth of her children 

239

1960s Kapiolani Medical Center- Hysterectomy, reason for surgery unknown. 

1998 Queens Medical Center- "surgery for the insides coming out the vagina" 

Transfusions: Not asked 

Current medications: Covera HS (verapamil) 240mg qd 

Tylenol 1 tab every 4-6 hrs pm back pain, last dose taken 1 day ago 

Aspirin- dosage unknown, last dose taken 10 days ago 

Allergies: Penicillin reaction unknown; told by doctor not to take penicillin 

Sulfa acute onset of "red rash and skin peeling in sheets" (1960s) 

Cortisone face swelling 

FH: Patient's father died in his 40s from “stomach cancer." Mother died in her 90s of a "stroke, and 

had diabetes mellitus. The patient has numerous siblings, some of whom are step-siblings. One sister 

has diabetes. Two of the step-siblings have died, causes unknown. Health status of the other siblings 

are unknown. There is no family history of bleeding disorders. 

40s 

“Stomach ca” 

90 

“Stroke” 

“DM” 

Personal Profile/SH: The patient is a retired hotel worker and widow. She now lives with her 

daughter. She denies the use of cigarettes, alcohol or illicit drugs. Her diet consists mostly of cereals, 

oatmeal and bread. She doesn't each much fruit or vegetables. 

ROS: 

General: See HPI. Denies weight loss, fever. 

Skin: Has no rash, itching, bruising. 

Eyes: Reports no blurry vision, other visual disturbances. 

Ears: Reports no hearing loss, tinnitus, pain, discharge, vertigo. 

Nose: Has "allergies” which cause runny nose, sneezing, cough. 

Mouth: Has no gingivitis, sore tongue, taste changes, dental problems 

Throat: Reports no pain, voice changes 

Pulmonary: Reports no chest pain, pneumonia, SOB, DOE, wheezing, sputum, hemoptysis 

Circulatory system: Has no chest pain, palpitations, dyspnea, PND, orthopnea, edema, syncope 

GI: See HPI; has no change in appetite, dysphagia, nausea, vomiting, rectal pain, hematemesis, 

diarrhea, peptic ulcer disease 

GU: Reports no frequency, nocturia, polyuria, urgency, dysuria, hematuria, hesitancy, urinary flow 

240

changes, retention, incontinence; has no history of kidney problems 

Female genitalia: See PMH. 

Breast: Not asked 

Sexual Hx: Not asked 

Endocrine system: Reports no neck mass, thyroid problems, exophthalmos, heat/cold intolerance, 

thirst changes 

Hemopoietic system: Has no lymph node enlargement, excessive bleeding, bruising, anemia 

Musculoskeletal system: See HPI and PMH. Has other joint or muscle pain. 

Nervous system: Has no history of head trauma, headaches, numbness, paralysis, convulsions, 

seizures, tremor, gait disturbances, coordination changes 

Mood: Not asked. 

PE: 

General Appearance: Patient appears well-nourished, appearing her stated age. She is lying 

comfortably in bed, in no evident distress. She is alert, oriented and cooperative. 

Vital Signs: Temp 96.0; Respirations 11; Oxygen sat 99% on Room Air; Supine- HR 89, BP 147/64; 

Standing- HR 110, BP 131/54 

Skin: Warm, dry, pale 

Head: Nontender over scalp 

Eyes: Acuity not tested. PERRL. Extraocular mucles function intact. Fundi not visualized due to 

cataracts. 

Ears: Acuity not tested. Pinna- no lesions, nontender. Canals- no bleeding. TMs not visualized due to 

cerumen obscuring view. Nose: normal pink mucosa nontender. no discharge. 

Mouth: Mucosa pink, moist, slightly pale. No lesions or bleeding. No tonsillar erythema or exudates. 

Neck: Supple. No thyromegaly, enlarged lymph nodes, jugular venous distention; no carotid bruits. 

Pulmonary: Lungs clear to percussion and ausculatation bilaterally, anteriorly and posteriorly 

Cardiac: No thrills, lifts or heaves. PMI palpated in left 5th ICS at the midclavicular line, non-bounding. 

Rate and rhythm are regular, normal S1 and S2. No murmurs, extra heart sounds heard. 

Abdomen: Soft, non-tender, non-distended. Normoactive bowel sounds in four quadrants. No 

hepatosplenomegaly by palpation.. 

Rectal (done by ER physician- reported as showing no masses, with “pink stool”. Bright red blood on 

glove which tested positive with hemoccult. 

Extremities: Full motion in all extremities. No clubbing, cyanosis, edema. Patient was slow to stand, 

and had an antalgic gait she attributed to back pain. 

Neuro: Alert and oriented x 3. Cranial Nerves: II - XII grossly intact. Speech slightly slurred, difficult to 

comprehend at times. Sensation normal to light touch and 10 gram monofilament; motor 5/5 in all 

extremities. DTRs 2+ in biceps, triceps, knees and ankles. No Babinski response is noted. 

Admission lab results: 

CBC: WBC 7.9, differential: Bands 7, Segs 50, Lymphs 37, Monocytes 5, Eos O, Baso 1 

Hgb 9.8 (was noted to have been 12.2, 2 days PTA), 

Hct 28.4 

MCV 93.9 

Platelet count 238 

BMP: Na 140 BUN 20 PT 12.3 

K 3.6 Creatinine 0.7 INR 1.0 

Cl 110 Glucose 135 PTT 22 

Bicarb 25 

241

Problem List 

Problem 

No. 

Date Onset Active Problems Date Resolved Inactive/Resolved 

Problems 

1. 1960s Allergic reaction to sulfa (rash, 

peeling skin) 

2. 1970s 1970s Hx of cervical cancer 

s/p TAHBSO 

3. 1970s Hx of “mild stroke x2 

slurred speech 

4. 1970s Hypertension 

5. 1998 Bladder prolapse s/p 

corrective surgery 

6. 2000 Degenerative disc disease 

chronic lower back pain 

7. 10-29-02 GI bleed 

8. 11-01-02 Anemia 

9. Unknown Hypercholesterolemia 

10. Unknown Unknown Bilateral cataracts 

s/p cataract surgery 

11. Unknown Allergy to penicillin 

(unknown reaction), cortisone 

(facial swelling) 

Problem #1: Bleeding per rectum 

Assessment: The patient has experienced 2 episodes of bloody stools in the past three days, during 

which time she has had more many bloody bowel movements. During the first episode, she describes 

bright red blood as well as “black clots.” In the most recent episode, she reports only bright red 

blood. She has been feeling weak since these episodes. In addition, there is evidence that this patient 

has had substantial blood loss including: (1) a decrease in hemoglobin from 12.2 to 9.8 in two days 

with normal MCV, which suggest an acute bleed; (2) orthostatic changes with an increase in HR of 

>20 and decrease in Systolic BP > 15mmHg suggest that the patient is hypovolemic, with a blood 

loss of greater than 1 Liter. In trying to identify the source of the bleed we must attempt to differentiate 

an upper GI bleed from a lower GI bleed, as well as confirm that the bleeding is from the rectum and 

not from the vagina or urethral orifice. Because the rectal exam confirms that there is blood in the 

rectum, we can assume the patient does have a GI bleed. With the reports of “bright red blood", it is 

likely that the patient is having a lower GI bleed, although a brisk upper GI bleed could also present 

as bright red blood per rectum. The “black clots” seen in the first episode suggest a possible upper GI 

bleed, in which the “clots” may have been melenic stool. 

The differential diagnosis of lower GI bleed include diverticulosis, colon cancer or polyps, ulcerative 

colitis, angiodysplasia, and hemorrhoids. Diverticulosis is likely as it most common in the elderly and 

can present 

with painless bright red blood per rectum that can result in massive hemorrhage. A diverticular 

242

hemorrhage is usually caused by erosion of a blood vessel by a fecalith within the diverticular sac. 

The patient did have some recent constipation which could have lead to the development of a 

fecolith. She took Metamucil for relief. It is unknown if the patient then had diarrhea, which can occur 

with Metamucil; but if she did, it is possible that the 

diarrhea in its rapid transit through the colon could have dislodged the fecalith resulting in injury to a 

blood 

vessel and hemorrhage. Diverticular bleeding stops spontaneously in the majority of patients. This 

was not the case for this patient. This could be due to the rupture of a large blood vessel in the colon, 

or it could be due to the patient's chronic use of aspirin (which can inhibit platelet aggregation 

resulting in decreased clotting ability for about 7-10 days, however, she claims to have not had 

aspirin for 10 days prior to admission). 

Colon cancer is also possible. Like diverticular disease, it is more common in the elderly. The patient 

displays signs and symptoms that are characteristic of a left colonic cancer- change in bowel habits 

(constipation, diarrhea) and bright red blood per rectum. Intestinal obstruction is also common with a 

left colon cancer, however the patient did not complain of abdominal pain or tenderness which would 

be expected with obstruction. A right colon carcinoma would present with an iron deficiency anemia 

due to chronic blood loss, which can be occult and thus unknown to the patient, and a dull vague 

abdominal pain. The patient did have a chronic dull lower right quadrant abdominal pain. She also 

had anemia (Hgb 9.8), however this anemia appears to be due to the acute blood loss and not iron 

deficiency as her Hgb was 12.2 two days prior to admission, and her MCV was normal. 

Ulcerative colitis should also be considered, although more commonly diagnosed in younger adults, 

there is also a small peak incidence among the elderly, ages 50-65. Although the patient is beyond 

this peak, UC must still be considered given that it's hallmark is bloody diarrhea. Most patients with 

UC will also have fever and weight loss, which this patient did not have. Angiodysplasia/AVM is also 

possible as it is most commonly seen in the elderly and presents with painless bright red blood per 

rectum. Hemorrhoids can be a cause of rectal bleeding, however there is usually associated pain 

and a palpable rectal mass, which this patient did not have. Infectious colitis is less likely in this 

patient as she is has no fever, abdominal pain or leukocytosis, all of which would be expected with an 

infectious process. The patient also denies any sick contacts. 

A brisk Upper GI bleed could also be responsible for this patient's rectal bleeding, however with such 

a large amount of blood loss, one would also expect some hematemesis, which did not occur. The 

differential would include gastritis, vascular ectasia, peptic ulcer disease and ruptured varices. 

Gastritis is very likely given the patient's chronic use of aspirin. However, she does not have 

abdominal pain which might be expected if it were severe enough to have caused this patient's 

bleeding. Peptic ulcer disease is less likely as pain is its predominant symptom, and the patient 

denied any abdominal or chest pain. It is important to rule-out a gastric ulcer in this patient, or to 

diagnose and treat it, as an untreated ulcer can increase her risk of developing gastric cancer. She is 

already at risk given her Japanese ethnicity and positive family history of gastric cancer. Ruptured 

varices is unlikely as the patient has no hematemesis and no history of liver disease which would 

cause the formation of varices. Her normal coagulation studies make liver disease unlikely. Given the 

numerous possible diagnoses for this patient's GI bleed it is imperative to have the patient to undergo 

both upper endoscopy and colonoscopy, especially given her history of both bright red blood per 

rectum and “black clots". 

Plan: Admit to acute care hospital with careful monitoring of vital signs. 

Plans: 

Diagnostic: 

-Place NG tube to assess for gastric bleeding 

243

-Consult a gastroenterologist for upper endoscopy and colonoscopy 

Treatment: 

-Type and crossmatch. Transfuse 2 units packed red blood cells to replace blood loss, since she is at 

risk to cntinue bleeding 

-No food or drink in preparation for endoscopy according to gastroenterologist instructions 

-Further treatment dependent on endoscopic findings. Consider initiate gastric acid blocking regimen 

prophylactically 

Patient education: 

-Inform patient of the possible diagnoses and the need for careful monitoring and testing 

-Inform patient of endoscopic procedures, explain risks and benefits, obtain informed consent 

-Inform patient of need for transfusion, explain risks and benefits, obtain informed consent 

Problem #2: Anemia 

Assessment: The patient has developed an acute anemia. Her hemoglobin had dropped 2.4 G/dL 

(from 12.2 to 9.8), which correlates with a decrease in hematocrit of approximately 7%. Hematocrit 

generally falls 2-3 points for every 500 mL of blood lost, making the estimated blood loss in this 

patient 3.5L. The normal MCV also suggests that the anemia is due to an acute blood loss. The 

normal coagulation studies rule-out a coagulopathy that may complicate the patient's GI bleed, 

although platelet dysfunction due to the patient's chronic aspirin use may exacerbate the bleed. The 

patient's orthostatic changes in heart rate and systolic BP is consistent with blood loss of greater than 

1 liter resulting in hypovolemia. The patient appears pale with pale mucous membranes and has 

complaints of weakness and light-headedness, which are all due to her anemia. It is important to 

transfuse this patient and increase her hemoglobin in order to avoid the complications associated with 

anemia and hypovolemia, such as high output cardiac failure and organ hypoperfusion, which may be 

of greater risk in the elderly. 

Plans: 

Diagnostic: 

-Monitor blood count every 4 hrs for continued bleeding and decrease in hemoglobin 

Treatment: 

- Place adequate intravenous access (2 large bore peripheral catheters) 

-Type and crossmatch. Transfuse 1 unit packed red cellss now. 

-Intravenous fluids: normal saline at 100cc/hour 

-Transfuse packed red cells to keep hemoglobin > 10 G/dL 


-Inform patient of need for transfusion, explain risks and benefits, obtain informed consent 

-Inform patient of signs and symptoms of worsening anemia that she should be aware of, such as 

worsening orthostatic hypotension, weakness, faintness, pallor, tachycardia. 

Problem #3: Back pain 

Assessment: The patient has been previously diagnosed with degenerative disc disease and suffers 

from chronic back pain. She regularly uses a back brace and cane to assist with mobilization. She 

occasionally has acupuncture treatments to relieve the pain. She had been taking aspirin on a regular 

basis for pain, and recently changed to Extra-Strength Tylenol which gives only partial relief. Given 

the possibility of gastritis, it is best for the patient to avoid aspirin and any other NSAID, especially 

with an active GI bleed. Once the bleeding has resolved, a specific COX-2 inhibitor could be 

considered, although there is still a risk of GI irritation with COX2 inhibitors, the risk is less than that of 

nonspecific NSAIDs. Given the patient's allergic reaction to sulfa, celecoxib is contraindicated; 

however, rofecoxib can be used. In clinical trials with rofecoxib, 3.9% of the patients had a reported 

sulfa sensitivity, none developed anaphylactic reactions. Another option would be to administer 

misoprostol along with the NSAID, in order to further protect the gastric mucosa. In order to 

244

completely avoid NSAIDs but still provide complete relief, tramadol could be considered. tramadol is 

a centrally acting analgesic which acts as an opiate agonist, although it is not opioid-derived. 

Tramadol does not irritate gastric mucosa, thus not causing an increased risk for GI bleed. Side 

effects reported for tramadol include constipation, dizziness, nausea, dry mouth, sweating and 

minimal cardiovascular effects including hypotension, tachycardia and syncope. Given the patients 

current gastritis, recent GI bleed and sulfa allergy, tramadol might be the best choice for pain relief in 

this patient should she request more complete relief than she is currently receiving with Tylenol; while 

being aware of possible hypotensive effects of this drug. 

Plans: 

Diagnostic: No further diagnostic studies at this time. 

Treatment: 

-Continue Tylenol 1 gram every 4-6 hrs as needed for back pain, not to exceed 4g daily 

-If better pain control is desired, consider starting tramadol 25 mg daily 


-Inform patient of the need to avoid NSAIDs 

-Inform patient of the daily maximum dose of Tylenol (4 G per day) and the adverse effects that could 

occur in the event of toxicity 

-Inform patient that a trial of tramadol could be started, with attention to added side effects, if better 

pain control is needed 

-------------------------------------------------------------------------------------- 

Resources: 

AHFS Drug Information, 2002 

Ferri. Practical Guide to the Care of the Medical Patient, 5th ed., 2001 

Myers. NMS Medicine, 4th ed" 2001 

 

Toby Best, MS 3 

245

Example of Ambulatory Note 

Problem List 

Problem 

# 

Date of 

onset 

Active Problems Date 

resolved 

Inactive/Resolved 

Problems 

1. 9/14/04 Pharyngitis 

2. 1998 Hypertension 

3. 1994 Obesity 

4. 1973 S/P Appendectomy 

Date of Examination: September 17, 2004 

ID: 40 year old Part Hawaiian woman 

SR: History obtained from the patient and medical records, which are reliable. 

RE: Scheduled office visit 

CC: Sore throat and fever x3 days 

Problem #1: Pharyngitis 

S: This 40 year old woman presents to the office per chief complaint. 3 days ago patient began 

having fever, chills, sore throat, rhinorrhea, myalgia, and fatigue. She denies cough, dyspnea, 

wheezing, otalgia, dysphagia, abdominal pain, nausea, vomiting, diarrhea or constipation. She has 

taken Advil, which improves symptoms. There are no sick contacts. Patient is able to swallow solids 

and liquids. 

Patient is taking oral contraceptives, and has no medication allergies. 

O: 

General: Well-groomed, cheerful woman who appears stated age. 

Not in acute distress. 

VS: T 97.5°F; P 78; R 12; BP 112/68; Wt 159 lbs.; Ht. 61 in. 

Skin: Warm, dry, intact. No rashes, petechiae, or bruising noted. 

Ears: Symmetrical auricles, canals nontender. Auditory canals clear and 

non-erythematous bilaterally. Tympanic membrane intact and pearly with clear cone of light 

bilaterally. 

Nose: 

Nares patent, septum midline, clear discharge. 

Mouth/Throat: Erythema and yellowish exudate present on posterior pharynx and 

tonsils bilaterally. Mucous membranes moist. Lips without cyanosis or lesions. Uvula midline. 

Tongue pink, moist. Parotids 

nonpalpable. 

Neck: 

Supple, no lymphadenopathy, no masses, non-tender to palpation. 

Trachea midline. 

Lungs: Clear to percussion and auscultation bilaterally. No wheezes, rales or coarse breath 

sounds. 

Heart: 

No thrills or heaves felt. RRR. S1 and S2 of equal intensity. No 

murmurs or rubs heard. 

246

A: While the differential diagnosis of acute pharyngitis in adults includes a number of bacterial and 

viral pathogens, the objective in evaluating a patient with pharyngitis is to identify those with group A 

streptococcus (GAS) pharyngitis. The patient’s symptoms and physical findings suggest possible 

group A streptococcal pharygitis. Although viruses are the most common cause of acute pharyngitis, 

Group A strep pharyngitis accounts for approximately 10% of acute pharyngitis in adults. It presents 

with the sudden onset of sore throat, tonsillar exudate, tender cervical adenopathy, and fever. 

Malaise, headache, abdominal pain and vomiting may also occur. The absence of fever or presence 

of cough, conjunctivitis, hoarseness, coryza, viral exanthem, and diarrhea strongly suggest a viral 

rather than a streptococcal etiology. The Centor criteria for predicting GAS have been the most widely 

used and accepted and include, 1) tonsillar exudate; 2) tender anterior cervical adenopathy; 3) fever 

by history; 4) absence of cough. If three or four of these criteria are met, the positive predictive value 

is 40% to 60%. However, the presence of less than three has a negative predictive value of 80%. By 

these criteria, this patient has a 40-60% probability of having GAS pharyngitis. 

Throat cultures have always been the "gold standard" for diagnosing GAS pharyngitis with a 

sensitivity of 90% and specificity of 95-99% if collected properly. However, cultures take 24 to 48 

hours to grow, therefore cannot be used to decide which patients merit antibiotic therapy. Thus, rapid 

antigen detection test (RADT) has assumed greater importance in managing acute pharyngitis. 

RADT uses enzyme or acid extraction of antigen from throat swabs followed by latex agglutination, 

co-agglutination, or enzyme linked immunoabsorbent assay (ELISA) procedures to demonstrate 

antigen-antibody complexes. The majority of RADTs that are currently available have a sensitivity of 

80-90% and specificity of >95%. It is also advantageous because it can yield results within 

approximately 10 minutes. Rapid identification and treatment of those with strep pharyngitis can 

reduce the risk of its spread, allowing the patient to return to school or work sooner, result in faster 

resolution of signs and symptoms (by 1-2 days), and can reduce the risk of suppurative complications 

and acute rheumatic fever. A positive result of either throat culture or RADT provides adequate 

confirmation of the presence of GAS in the pharynx. In children, a negative RADT should be 

confirmed with a throat culture result while in adults a negative RADT is sufficient to exclude this 

diagnosis, because the risk for acute rheumatic fever in adults is extremely low. Serologic tests for 

antistreptococcal antibody titers reflect past and not present immunologic events and are of no value 

in the diagnosis of acute pharyngitis. 

The major goal of identifying patients with GAS pharyngitis is to prescribe antibiotics to these patients 

and not treat the others, especially those with pharyngitis caused by a virus in order to limit antibiotic 

resistance. Recent guidelines from the Infectious Diseases Society of America (IDSA) regarding 

principles of management in cases of sore throat include: (1) use of clinical and epidemiologic 

features to distinguish patients who may have GAS pharyngitis; and (2) antibacterial treatment only 

for cases confirmed with a laboratory test (culture or rapid test). In contrast, a position paper by the 

American College of Physicians–American Society of Internal Medicine/American Academy of Family 

Physicians/US Centers for Disease Control and Prevention, while endorsing the IDSA approach in 

children, recommends a departure from the principle of laboratory confirmation of all adult cases. The 

suggested strategies are: empirically treat patients who have all four Centor clinical criteria (fever, 

tonsillar exudate, tender anterior cervical adenopathy, and absence of cough); do not treat nor 

perform diagnostic tests on patients with zero or one criterion; perform RADT on those with two or 

three criteria and use antibiotic treatment for patients with positive RADT results. Empiric treatment 

of all patients with 3 or 4 Centor criteria can result in unnecessary antibiotic exposure to at least 50 

percent of patients. Some authorities, including the Infectious Diseases Society of America, find this 

unacceptable and recommend antibiotics only if there is a positive RADT or culture. This criterion will 

result in undertreatment of 10-20%, but the consequences of undertreatment in adults are rare. This 

patient has three out of the four Centor criteria, so under both current recommendations patient 

should have a RADT done to determine if antibiotic therapy is warranted. 

247

Most oral antibiotics must be administered for the conventional 10-day regimen. Penicillin remains 

the treatment of choice in treating acute streptococcal pharyngitis because of its proven efficacy, 

safety, narrow spectrum, and low cost. Amoxicillin is often used in young children, while erythromycin 

is a suitable alternative for patients who are allergic to penicillin. First-generation cephalosporins are 

also acceptable for patients allergic to penicillin who do not manifest immediate-type hypersensitivity 

to beta-lactam antibiotics. Intramuscular benzathine penicillin G is preferred for patients who are 

unlikely to complete a full 10-day course of oral therapy. Antibiotics can affect the metabolism and/or 

efficacy of oral contraceptives, which the patient is using. Antibiotic therapy with penicillin should be 

started if patient’s RADT is positive. 

Symptomatic treatment, including antipyretics, fluids, and gargles, can be helpful. One study showed 

that herbal tea (Throat coat), containing ingredients such as licorice root that may relieve irritation, 

provided significant temporary relief to the intensity of sore throat with swallowing compared to 

placebo tea. However herbal teas should be used with caution in this patient because of her 

hypertension and potential medication interactions. Licorice may cause hypokalemia, so should 

probably not be used by a patient taking a thiazide diuretic. Regardless of RADT results, patient 

should be advised to use acetaminophen for pain and fever, drink increased amounts of fluid, and 

possibly gargle for symptomatic relief. Side effects of NSAIDs can worsen hypertension, and there 

are potential drug interactions with antihypertensive medications including β-blockers. Also, use 

caution in recommending a decongestant for this patient because of her hypertension. However, her 

hypertension is well-controlled, so it would probably be safe to use medications such as 

pseudephedrine. 

Although complications of GAS are rare in adults, they include acute rheumatic fever, acute 

glomerulonephritis, toxic shock syndrome, tonsillopharyngeal abscess, otitis media, sinusitis, 

necrotizing fasciitis, bacteremia, and meningitis. If patient tests positive for GAS, she should be 

educated on the possible complications and the signs and symptoms to watch for. She should also 

be reminded to return if her symptoms become worse or do not improve within a few days. 

P. Diagnostic 

Run a rapid antigen detection test to check for Group A Streptococcus pharyngitis. 

Therapeutic 

If RADT positive: oral penicillin 250 mg PO three times a day for 10 days. Pt should be cautioned use 

a back up method of contraception while taking the antibiotics because of the potential drug 

interactions. 

Acetaminophen 500 mg PO every 4-6 hours as needed for fever 

Salt gargles, tea to relieve sore throat. 

Patient Education 

If RADT negative: Explain rationale for not using antibiotics. 

If RADT positive: Stress importance of finishing the 10-day course of antibiotics, remind patient that 

she is still contagious until she has been on antibiotics for 24 hours, and educate her on the signs and 

symptoms of possible complications. 

Encourage patient to drink adequate amounts of fluid. Educate on “recipe” of NaCl solution for 

gargle- ¼ tsp table salt to a full cup of water, and remind her not to swallow this salty solution!. 

Reassure patient that asymptomatic household contacts do not need a routine culture of throat swab 

specimen, unless there is a “ping-pong” spreading of GAS pharyngitis within the family. 

Return for a follow-up visit if symptoms do not improve within a few days. 

Follow-up in 2-3 days if symptoms do not improve. 

248

Problem #2: Hypertension 

S. No chest pain, palpitations, dizziness, headaches, shortness-of-breath, wheezing, orthopnea, 

PND or edema. Pt is taking Ziac (bisoprolol/hydrochlorothiazide) 5 mg/6.25 mg, two tablets in the 

morning, and denies any symptomatic side effects from the medication. She exercises by walking for 

30 minutes three times a week. She eats a well-balanced diet and limits her sodium intake. 

O: 

VS: As above 

Eyes: Sclera clear, conjunctiva pink, no discharge. Extraocular muscles 

intact, pupils equal, round, reactive to light and accommodation. 

No papilledema, nicking, or cotton wool spots. 

Neck: No jugular venous distention 

Lungs: 

As above 

Heart: As above 

Circulation: Posterior tibial and pedal pulses 2+ bilaterally. No jugular venous 

distention. 

Extremities: No edema. 

A: Patient’s blood pressure is well-controlled with lifestyle modifications and Ziac. The JNC VII 

guidelines indicate that she is below goal blood pressure of

W., et al. JAMA. 2004 Apr 7;291(13):1587-95. 

“Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults” Snow et al. Ann Intern 

Med.2001; 134: 506-508. 

Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis, 

Infectious Disease Society of America. 

Harrison’s Online 

 

N.O. Itall, MS 3 

250

CLINICAL SKILLS EXAMINATION (CSE) 

STUDENT INSTRUCTIONS 

(Revised 6/12) 

DESCRIPTION 

The CSE is a practical examination consisting of 5 - 10 clinical problems including patient 

encounters and writing stations. The examination requires you to interact with standardized patients 

who volunteer for this exercise. These patients may have real clinical findings or are carefully trained 

to simulate patients with “real” medical problems. You should interview and examine these patients 

as if they are being seen in an actual patient care situation. 

GENERAL PROCEDURES 

You will have 15 minutes with each patient. You are responsible for pacing your visit with the patient. 

The timer will announce the beginning of each patient session. You will be warned when there are 5 

minutes remaining in each station, when to rotate to and begin the next station. Do not enter an exam 

room until told to begin. Each of you will start at a different point along the exam route and will 

continue to rotate until all stations are completed. If 2 (or more) students end up in the same station 

at the same time, notify the exam monitor immediately. 

Please knock before entering a patient's room. If you are finished evaluating the patient before the 

15 minutes are up, you may leave the station and begin answering questions in the writing station. 

Introduce yourself to the standardized patients as you would introduce yourself to any patient. End 

the encounter as you would end any encounter. On the door of every patient's room you will find 

student instructions in a RED FOLDER. Do not open the RED FOLDER until the timer says, “begin 

the encounter.” Reading the student instructions is considered part of your 15 minutes with the 

patient. In general, there will be enough time to review the instructions for 1 to 2 minutes and still 

complete your task with the patient. 

The instructions will give you the patient’s name, age, gender and reason for the visit. The 

instructions may also indicate where you are seeing the patient (outpatient clinic, emergency room, 

etc.), and the time of day (if it is different from the current time). The vital sign including the 

temperature, heart rate, blood pressure and respiratory rate may also be given. You should accept 

the vital signs as accurate and you do not need to repeat them unless you feel the case specifically 

requires it. 

Your task with the patient will be specifically defined. For example the instructions may tell you to 

take an appropriate history and counsel the patient . . . or take an appropriate history and perform a 

focused physical examination. You are to perform a focused examination of each patient that is 

consistent with the instructions provided. Hand washing is an essential practice when seeing patients 

and should be considered as a requirement during this examination. Facilities for washing your 

hands are available in each examining room. 

READ THE INSTRUCTIONS CAREFULLY BEFORE ENTERING EACH STATION. Do not take the 

RED FOLDER containing the student instructions into the examination room. A copy of the 

instructions will be placed in each room for your reference. If you feel it is necessary, you may take 

notes on the blank sheets provided on your clipboard. PLEASE DO NOT WRITE ON THE STUDENT 

INSTRUCTIONS. 

251

You should not perform rectal, genital, breast or corneal reflex examinations on your patients. If you 

feel that one or more of these maneuvers should be included as part of the work up for the patient 

you should inform the patient (e.g. “Mrs. Smith, the next step would be to do a pelvic and rectal 

examination on you”) and/or include it as part of your proposed diagnostic evaluation. As part of the 

encounter, you should provide the patient with your initial impression and initial management plan. 

End the encounter with the patient as you would end any patient encounter. 

You will receive a supply of “BUSINESS CARDS” pre-printed with your Examinee Identification 

Number. Before leaving the patient's rooms please leave one card with the patient (e.g. "If you have 

any questions or need to get in touch with me, here is my card"). This will allow the standardized 

patient to complete your evaluation forms. If you forget to give your card to the patient please leave 

it with the monitor and he/she will bring it in to the patient. ONCE YOU LEAVE THE PATIENT'S 

ROOM, YOU ARE NOT ALLOWED TO RE-ENTER FOR ANY REASON. 

WRITING STATIONS (PATIENT NOTE): 

Immediately after each patient encounter will begin a “writing station” where you will answer specific 

questions related to the encounter. Depending on the station, you will be writing your answers on 

paper or entering them on a computer. 

For stations requiring paper and pen, take one TEST BOOKLET from the blue folder located at the 

writing station. WRITE IN YOUR ASSIGNED STUDENT EXAMINEE ID# ON YOUR TEST 

BOOKLET and then begin answering the questions. You will have 10 minutes to answer the 

questions and complete any evaluation forms. Remember to write clearly, as we must be able to 

read your writing to grade it. When you have finished, turn your paper faced down on the desk. A 

proctor will pick up these forms. 

For stations requiring computer entry, log on to the computer using your UH USERNAME AND 

PASSWORD. Enter the Patient’s ID Number (located in a blue folder next to the computer monitor) 

to access the entry form for the station and begin answering the questions. You will have 10 minutes 

to answer the questions and complete any evaluation forms. When you have finished, remember to 

LOGOUT. 

In most stations, you will be asked to describe the significant positive and negative clinical findings 

uncovered during your interaction with the patient that will allow you to make clinical decisions, your 

differential diagnosis in the order of likelihood, and/or your INITIAL DIAGNOSTIC management plan 

(See Attached Sample Patient Note form). LIST only one item for each numbered blank line. Be as 

specific as possible. 

BREAKS 

You are asked not to leave the examination area during the break times and to refrain from 

discussing the cases with each other. 

CONTENT OF EXAM 

The clinical situations for this examination reflect the “General Core Clinical Competencies and 

“Training Problems” described in the Medicine 531/532 Student Handbook. You are being evaluated 

based on checklists and rating scales completed by the patient and by the responses you provide in 

the test booklet regarding your findings (writing stations). You are not allowed to consult any medical 

references during the exam. 

252

PAGERS/CELLULAR PHONES 

Cellular phones and pagers will not be allowed inside the examination area. We can hold 

them for you while you take the examination, but we will not be responsible for loss or damages. 

Please plan accordingly. 

EQUIPMENT 

1. STETHOSCOPE 

2. REFLEX HAMMER 

3. PENS with black ink 

4. NAME TAG 

5. PROPER ATTIRE. You should dress as you would to see patients. 

6. Otoscopes, ophthalmoscopes, sphygmomanometers, tongue blades, reflex hammers, drapes, clip 

boards and other supplies will be available in each examination room. 

GRADING AND FEEDBACK 

Student performance on each station is scored based on the following component scores, weighted 

as follows: 

Communication/Interpersonal Skills 30-40% 

Hx-Taking/Physical Exam/Counseling 40-50% 

Problem Solving (writing stations) 10-30% 

The Total Examination Score is calculated based on the average of the scores on each station. 

Students must achieve Clerkship Level Competency on this examination to receive credit for Med 

531, and Graduation Level Competency to receive credit for Med 541. 

Each student will receive a feedback letter with their Total Score and breakdown of their component 

scores. In addition, the average ratings by the standardized patients on specific communication skills 

(introducing self, active listening, showing interest etc), will also be provided. Unfortunately, we 

cannot return the actual checklists and written test materials without compromising the cases which 

may be used on future examinations. 

IMPORTANT REMINDER: 

You must have your UH Login and Password to complete this examination. 

253

FREQUENTLY ASKED QUESTIONS: 

Q1: How can I best prepare for this examination? 

A1: Review the Training Problems and General Core Clinical Competencies sections of your 

Med531/532 Student Handbook. For each of the Training Problems listed, be able take an 

appropriate history and focused physical examination. Understand how specific signs and symptoms 

relate to the differential diagnosis for each problem. Most importantly, review and practice good 

communication and interpersonal skills when seeing patients during the rotation. 

Q2: Are all the stations equal in length and difficulty? 

A2: Some stations, especially those requiring both a focused history and focused physical 

examination, seem to take everyone longer than other stations, although there is great variability 

among students. All of the stations are designed to be completed in the time allotted. The more 

difficult stations require students to focus their examination on obtaining the most relevant clinical 

information. The passing score for each station is adjusted for case difficulty. 

Q3: What does the interstation exercise (writing station or patient note) look like? 

A3: See example below. 

254

JOHN DOE -- PATIENT NOTE 

EXAMINEE ID # ____ ____ 

DATE: __/__/__ 

HISTORY: Include significant positives and negatives from history of present illness, past medical 

history, review of system(s), social history and family history. 

PHYSICAL EXAMINATION: Indicate only pertinent positive and negative findings related to the 

patient’s chief complaint. 

DIFFERENTIAL DIAGNOSES: In order of 

likelihood (with 1 being most likely), list up to 

5 potential or possible diagnoses for this 

patient’s presentation (in many cases, fewer 

than 5 diagnoses are likely). 

1. 

2. 

3. 

4. 

5. 

DIAGNOSTIC WORK UP: List immediate 

plans (up to 5) for further diagnostic workup. 

1. 

2. 

3. 

4. 

5. 

255

NBME SUBJECT EXAM IN INTERNAL MEDICINE 

256

MEDICINE 

General Principles 1%-5% 

Organ Systems 95%-99% 

Immunologic Disorders 5%-10% 

Diseases of the Blood and Blood-forming Organs 

5%-10% Diseases of the Nervous System and Special Senses 

5%-10% Cardiovascular Disorders 

15%-20% Diseases of the Respiratory System 

15%-20% Nutritional and Digestive Disorders 

10%-15% Gynecologic Disorders 

1%-5% 

Renal, Urinary, and Male Reproductive System 

10%-15% Disorders of the Skin and Subcutaneous Tissues 

5%-10% Diseases of the Musculoskeletal System and Connective 

Tissue 5%-10% Endocrine and Metabolic Disorders 

Physician Tasks 5%-10% 

Promoting Health and Health Maintenance 

10%-15% Understanding Mechanisms of Disease 

20%-25% Establishing a Diagnosis 

40%-45% Applying Principles of Management 

20%-25% 

1. A 22-year-old woman with a 10-year history of 

asthma comes to the physician because she has had to 

increase her use of her albuterol inhaler during the past 6 

weeks. Her asthma was previously well controlled with 

inhaled glucocorticoids. She has a 2-year history of 

generalized anxiety disorder controlled with fluoxetine and a 

5-year history of migraines. The migraines were well 

controlled with sumatriptan until 4 months ago when she 

began to have headaches twice weekly; propranolol was 

added to her regimen at that time. She has been taking an 

oral contraceptive for the past year. She says she has been 

under increased stress at graduate school and in her 

personal life during the past 3 months; during this period, 

she has been drinking an average of four cups of coffee 

daily (compared with her usual one cup daily). She does not 

drink alcohol or use illicit drugs. She appears mildly anxious 

but is not in respiratory distress. Scattered end-expiratory 

wheezes are heard. The remainder of the examination 

shows no abnormalities. Which of the following is the most 

likely cause of the exacerbation of this patient's asthma? 

(A) Fluoxetine therapy 

(B) Increased caffeine intake 

(C) Oral contraceptive therapy 

(D) Propranolol therapy 

(E) Sumatriptan therapy 

2. A 28-year-old woman has palpitations that occur 

approximately once a week, last 1B5 minutes, and consist of 

rapid, regular heart pounding. The episodes start and stop 

suddenly and have not been associated with chest discomfort 

or dyspnea. There is no history of heart problems. She drinks 

two to three cups of coffee daily. She rarely drinks alcohol 

and does not smoke. Her pulse is 96/min and regular, and 

blood pressure is 120/88 mm Hg. A stare and lid lag are 

noted. The thyroid gland is firm and 1.5 times larger than 

normal. There is a midsystolic click at the apex and a grade 

2/6, early systolic murmur at the upper left sternal border. An 

ECG is normal except for evidence of sinus tachycardia. 

Which of the following is the most appropriate next step in 

diagnosis? 

(A) Ambulatory ECG monitoring 

(B) Measurement of serum thyroidstimulating 

hormone concentration 

(C) Measurement of urine 

catecholamine concentration 

(D) MUGA scan 

(E) Echocardiography 

257

3. A study is conducted to assess the benefits of a new drug to 5. Two days after receiving 3 units of packed red blood cells for 

reduce the recurrence of colonic polyps. The results postpartum hemorrhage, a 24-year-old woman has 

show a number needed to treat (NNT) of 16. Which of fatigue and slight jaundice. Laboratory studies show: 

the following is the most accurate interpretation of this 

result? 

Hemoglobin 8.8 g/dL 

(A) For every 16 patients treated, 1 would 

Hematocrit 28% Serum total 

benefit from the new drug 

bilirubin 5 mg/dL 

(B) For every 100 patients treated, 16 would 

benefit from the new drug 

(C) The new drug is 1.6 times more 

beneficial than a placebo 

(D) 93% of patients taking the new drug 

would benefit from it 

(E) 84% of patients taking the new drug 

would not have any benefit from it 

4. A previously healthy 57-year-old woman comes to 

the physician 1 week after noticing a lump under her right 

arm. She is concerned that it is breast cancer because both 

her mother and maternal aunt died of breast cancer. She 

does not smoke, drink alcohol, or use illicit drugs. She has 

avoided the sun for the past 10 years. She notes that her skin 

has never tanned but always burned and freckled when 

exposed to the sun. She exercises daily on a stationary 

bicycle and eats a well-balanced diet. Her temperature is 

37°C (98.6°F), pulse is 82/min and regular, respirations are 

14/min, and blood pressure is 130/74 mm Hg. There are 

numerous freckles over the entire body. Examination of the 

right breast shows a 0.6-cm, flat, brown lesion; the lesion is 

mottled with deep purple and black areas and has an irregular 

border. There are no breast masses, dimpling, peau d'orange, 

or nipple discharge. The patient says that the lesion has been 

present for 1 year, but she has never had it examined. There 

is a firm, nontender mass in the right axilla. Examination 

shows no other abnormalities. Which of the following is the 

most likely diagnosis? 

(A) Basal cell carcinoma 

(B) Fibrocystic changes of the 

breast (C) Malignant melanoma 

(D) Mastitis 

(E) Pigmented nevus 

(F) Port-wine stain 

(G) Squamous cell 

carcinoma (H) Superficial breast 

carcinoma 

Liver tests are otherwise within normal limits. Which of 

the following is the most appropriate next step in 

diagnosis? 

(A) Cytomegalovirus antibody titer 

(B) Direct and indirect antiglobulin 

(Coombs) tests 

(C) Monospot test 

(D) Serology for hepatitis B 

markers (E) Ultrasonography of the 

gallbladder 

6. A 30-year-old man has had nausea, vomiting, and 

severe colicky right flank pain radiating into the thigh for 4 

hours. He is afebrile. There is right costovertebral angle 

tenderness. Urinalysis shows RBCs too numerous to count 

and no bacteria. Which of the following is the most likely 

diagnosis? 

(A) Acute glomerulonephritis 

(B) Bacterial cystitis 

(C) Benign prostatic hyperplasia 

(D) Bladder carcinoma 

(E) Renal cell carcinoma 

(F) Urinary tract tuberculosis 

(G) Urolithiasis 

7. A 66-year-old woman comes to the emergency 

department 1 hour after the sudden onset of retrosternal 

chest discomfort accompanied by nausea and diaphoresis. 

She has hypotension, jugular venous distention, and a 

murmur of tricuspid regurgitation. An ECG shows STsegment 

elevation in the right precordial leads. Which of the 

following is the most likely diagnosis? 

(A) Constrictive pericarditis 

(B) Dissecting aortic aneurysm 

(C) Pericardial tamponade 

(D) Pulmonary emboli 

(E) Right ventricular infarction 

258

8. A 20-year-old African American woman comes to the physician because of a 6-month history of diffuse joint pain, 

especially in her hips and knees. During this period, she occasionally has had a rash on her nose and cheeks. She has no 

history of serious illness and takes no medications. Her temperature is 38.1°C (100.5°F). Examination shows warmth and 

swelling of the knees. Laboratory studies show: 

Which of the following is the most likely diagnosis? 

(A) Ankylosing spondylitis 

(B) Gouty arthritis 

(C) Psoriatic arthritis 

(D) Reactive arthritis 

(E) Rheumatoid arthritis 

(F) Septic arthritis 

(G) Systemic lupus 

erythematosus 

Hemoglobin 10.5 g/dL Erythrocyte sedimentation rate 40 mm/h 

Serum 

Urea nitrogen 30 mg/dL Creatinine 1.8 

mg/dL 

9. A 37-year-old man with type 1 diabetes mellitus 

comes to the physician for a routine examination. His only 

medication is insulin. His pulse is 72/min, respirations are 

12/min, and blood pressure is 138/88 mm Hg. Funduscopic 

examination shows microaneurysms and hemorrhages. 

Sensation to vibration and light touch is decreased over the 

lower extremities. His serum creatinine concentration is 1.6 

mg/dL. A 24-hour urine collection shows 550 mg of protein. 

Treatment with which of the following is most likely to slow 

progression of this patient's renal disease? 

(A) Atenolol 

(B) Clonidine 

(C) Hydralazine 

(D) Hydrochlorothiazide 

(E) Lisinopril 

10. A 50-year-old man is admitted to the hospital within 

2 hours of the onset of nausea, vomiting, and acute 

crushing pain in the left anterior chest. He has a family 

history of early coronary artery disease. The pain does not 

subside with the administration of nitroglycerin, sublingually. 

An ECG shows ST-segment elevation in leads aVL and V2 

through V4. Which of the following is the most appropriate 

management to decrease myocardial damage and 

mortality? 

(A) Administration of digitalis 

(B) Administration of lidocaine 

(C) Administration of quinidine 

(D) Coronary artery bypass grafting within 1 

week 

(E) Thrombolytic therapy 

11. A previously healthy 67-year-old woman comes to 

the physician with her husband because of a 4-month history 

of a resting tremor of her right arm. Her husband reports that 

her movements have been slower and that she appears less 

stable while walking. Examination shows increased muscle 

tone in the upper extremities that is greater on the right than 

on the left. There is decreased right arm swing. Her gait is 

slow and shuffling. Which of the following is the most likely 

explanation for this patient's symptoms? 

(A) Bilateral frontal lobe 

degeneration 

(B) Decreased dopaminergic input to the 

(C) striatum Decreased serotonergic activity in the brain 

stem 

(D) Excessive output of oxytocin 

(E) Excessive thalamic output of 

norepinephrine 

12. A 47-year-old man comes to the physician because 

of a 4week history of increased thirst and urination. He has 

had a 23-kg (50-lb) weight gain during the past 2 years. He 

has no history of serious illness and takes no medications. 

His mother and maternal grandfather have type 2 diabetes 

mellitus. The patient does not smoke and drinks one beer 

every night. He is 175 cm (5 ft 9 in) tall and now weighs 104 

kg (230 lb); BMI is 34 kg/m 2 . His pulse is 90/min, and blood 

pressure is 150/88 mm Hg. The remainder of the 

examination shows no abnormalities. His serum glucose 

concentration is 330 mg/dL. Which of the following is the 

most likely underlying cause of this patient's increased 

serum glucose concentration? 

(A) Autoimmune destruction of islet cells 

(B) Chronic pancreatitis 

(C) Exogenous production of 

corticosteroids 

(D) Insulin resistance 

(E) Pancreatic cancer 

259

13. A previously healthy 39-year-old woman is brought 

to the physician because of a tingling sensation in her 

fingers and toes for 2 days and rapidly progressive 

weakness of her legs. She had an upper respiratory tract 

infection 2 weeks ago. She was unable to get up from bed 

this morning. Examination shows weakness of all four 

extremities, distal greater than proximal. Deep tendon 

reflexes are absent. Sensation is mildly decreased over the 

feet. Which of the following is the most likely diagnosis? 

(A) Guillain-Barré syndrome 

(B) Multiple sclerosis 

(C) Myasthenia gravis 

(D) Poliomyelitis 

(E) Tick paralysis 

14. A previously healthy 77-year-old woman who 

resides in a skilled nursing care facility is brought to the 

emergency department 6 hours after the onset of acute 

midback pain that began while lifting a box. The pain does 

not radiate, and she has no other symptoms. She continues 

to carry out her daily activities. She appears to be in mild 

distress. She is 157 cm (5 ft 2 in) tall and weighs 47 kg (104 

lb); BMI is 19 kg/m 2 . Examination shows mild tenderness 

over T11. There is no tremor. Serum studies show a calcium 

concentration of 9.1 mg/dL, a urea nitrogen concentration of 

12 mg/dL, and a creatinine concentration of 0.5 mg/dL. An x- 

ray of the dorsal and lumbar spine shows an anterior wedge 

fracture of T11. In addition to treating the pain, 

supplementation with which of the following is most likely to 

improve this patient's underlying condition? 

(A) 25-Hydroxycholecalciferol 

(B) Levothyroxine 

(C) Selenium 

(D) Vitamin C 

(E) Vitamin E 

15. A 52-year-old woman comes to the physician 

because of a 3-month history of diarrhea and intermittent 

abdominal pain that radiates to her back. The pain is 

exacerbated by eating. She describes her stools as greasy, 

foul-smelling, and difficult to flush. She has had a 4.5-kg 

(10-lb) weight loss during the past 4 months. She has a 

history of chronic alcohol abuse. Examination shows mild 

epigastric tenderness. An x-ray of the abdomen shows 

calcifications in the epigastrium. Which of the following is 

the most likely diagnosis? 

(A) Bacterial overgrowth 

(B) Celiac disease 

(C) Lactose intolerance 

(D) Malabsorption of bile salts 

(E) Pancreatic insufficiency 


because of an 8-month history of progressive shortness of 

breath. The shortness of breath initially occurred only with 

walking long distances but now occurs after walking ¼ mile 

to her mailbox. She also has a daily morning cough 

productive of whitish tan sputum. She has had no chest pain, 

palpitations, orthopnea, or paroxysmal nocturnal dyspnea. 

She has smoked one pack of cigarettes daily for 52 years. 

Her pulse is 88/min, respirations are 20/min, and blood 

pressure is 144/90 mm Hg. Examination shows a barrelshaped 

chest. Breath sounds are decreased, and faint 

expiratory wheezes are heard in all lung fields. There is no 

peripheral edema. An x-ray of the chest shows no 

abnormalities except for hyperinflation. Which of the 

following is the most likely diagnosis? 

(A) Angina pectoris 

(B) Asthma 

(C) Chronic obstructive pulmonary 

disease 

(D) Chronic pulmonary embolism 

(E) Congestive heart failure 

(F) Panic disorder 


because of a 10-day history of pain in multiple joints. She 

first had pain in her right elbow, and then her right shoulder, 

and now has pain, redness, and swelling in her left knee that 

began 2 days ago. She currently has no pain in the right 

shoulder and elbow. There is no history of trauma. She is 

sexually active, and she and her partner use condoms for 

contraception inconsistently. Examination of the left knee 

shows warmth, erythema, tenderness, and soft-tissue 

swelling. Range of motion of the knee is limited to 10 

degrees of flexion. The remainder of the examination, 

including pelvic examination, shows no abnormalities. 

Arthrocentesis of the knee joint yields 10 mL of cloudy fluid 

with a leukocyte count of 18,300/mm 3 (97% segmented 

neutrophils). Microscopic examination of the leukocytes 

within the joint fluid is most likely to show which of the 

following? 

(A) Acid-fast bacteria 

(B) Cuboidal positively birefringent crystals 

(C) Gram-negative diplococci 

(D) Gram-positive cocci in clusters 

(E) Needle-shaped negatively birefringent 

crystals 

18. A 47-year-old woman comes to the physician for a 

routine health maintenance examination. She feels well and 

has no history of serious illness. Her mother, brother, and 

sister have hypertension. The patient's pulse is 84/min, and 

blood pressure is 138/85 mm Hg. Examination shows no 

abnormalities. The most appropriate recommendation is 

decreased intake of which of the following? 

(A) Calcium 

(B) Carbohydrates 

(C) Potassium 

(D) Protein 

(E) Sodium 

260

19. A 32-year-old man comes to the physician because 

of a 12day history of abdominal cramps and bloating, 

diarrhea, and flatulence. He says that he started a new 

exercise program 2 weeks ago and has been consuming a 

high quantity of yogurt bars, peanut butter, and protein- and 

calorie-enriched milk shakes to "bulk up." He has no history 

of serious illness and takes no medications. His temperature 

is 37°C (98.6°F). The abdomen is distended, nontender, and 

tympanitic to percussion. Bowel sounds are increased. The 

remainder of the examination shows no abnormalities. Which 

of the following is the most likely cause of this patient's 

symptoms? 

(A) Allergy to peanuts 

(B) Fungal overgrowth in the small 

bowel 

(C) Incarcerated hernia 

(D) Irritable bowel syndrome 

(E) Lactase deficiency 

20. A 22-year-old college student comes to student 

health services because of a 7-day history of low-grade 

fever, sore throat, fatigue, and general malaise. One month 

ago, she had a painless vulvar ulcer that resolved 

spontaneously; she has been otherwise healthy. Her last 

menstrual period was 3 weeks ago; she uses tampons 

regularly. She is sexually active and has had three partners 

since the age of 15 years; she uses an oral contraceptive. 

Her temperature is 38°C (100.4°F), pulse is 100/min, and 

blood pressure is 110/60 mm Hg. Examination shows a rash 

over the palms and soles and mild cervical 

lymphadenopathy. Pelvic examination shows no 

abnormalities. Which of the following is the most appropriate 

pharmacotherapy? 

(A) Acyclovir 

(B) Dexamethasone 

(C) Interferon 

(D) Penicillin 

(E) Zidovudine (AZT) 

261

Answer Form for Medicine Subject Test Sample Questions 

(Questions 1-20) 

1. _____ 

2. _____ 

3. _____ 

4. _____ 

5. _____ 

6. _____ 

7. _____ 

8. _____ 

9. _____ 

10. _____ 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

19. 

20. 

262

Answer Key for Medicine Subject Test Sample Questions 

(Questions 1-20) 

1. D 11. B 

2. B 12. D 

3. A 13. A 

4. C 14. A 

5. B 15. E 

6. G 16. C 

7. E 17. C 

8. G 18. E 

9. E 19. E 

10. E 20. D 

263

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