UCSF/SFGH Family & Community Medicine Residency Program
EDUCATIONAL OBJECTIVES
A. Normal cardiovascular anatomy and physiology
B. Changes in cardiovascular physiology with age and pregnancy
C. Risk factors
1. Coronary artery disease
a. Hyperlipidemia
b. Cigarette smoking
c. Genetic predisposition
d. Sedentary life style
e. Hypertension
f. Emotional stress
g. Diabetes
h. Excess weight
i. Nutrition
j. Hormonal status
2. Acute rheumatic fever
D. Cardiovascular history
E. Cardiac-centered physical examination
F. Noninvasive examinations
1. Electrocardiography, 12 lead and continuous monitoring
2. Chest radiography
3. Stress testing, including exercise and pharmacologic techniques
4. Echocardiography/Doppler imaging, both rest and stress
5. Radioisotope imaging, both rest and stress
6. Vascular Doppler and ultrasound examinations
G. Invasive examinations
1. Diagnostic cardiac catheterization and angiography
2. Diagnostic carotid and peripheral vascular angiography
3. Internal monitoring devices: central venous and peripheral arterial
5. Electrophysiologic studies
6. Indications and contraindications of therapeutic interventions
a. Coronary artery bypass
b. Angioplasty: percutaneous, including balloon atherectomy and laser
c. Pacemaker insertion
d. Valve replacement/repair, percutaneous balloon valvotomy
e. Electrophysiologic ablation
H. Relevant laboratory interpretation, including serum enzymes, isoenzymes and lipids
I. Specific diseases/conditions
1. Coronary artery disease
a. Stable/unstable angina and acute coronary syndromes
b. Myocardial infarction, with and without complications
c. Cardiogenic shock
d. Arrhythmias
e. Papillary muscle dysfunction and rupture
f. Ventricular rupture
e. Aneurysm
g Sudden death
2. Syncope
3. Arrhythmias, including SVT, Atrial fibrillation, reentrant, bradyarrhythmias
4. Hypertension
a. Essential
b. Secondary
c. Pulmonary
5. Pulmonary heart disease
a. Cor pulmonale
6. Congestive heart failure
a. systolic dysfunction
b. diastolic dysfunction
7. Thromboembolic disease
8. Valvular heart disease
a. rheumatic
b. congenital
c. degenerative
d. Mitral valve prolapse syndrome
9. Congenital heart disease
a. Common left to right shunts (acyanotic) and right to left shunt (cyanotic)
b. Common obstructive problems
10. Dissecting aneurysm
11. Innocent heart murmurs
12. Peripheral vascular disease
a. Aneurysm
b. Carotid atherosclerosis
c. Arterial disease
d. Arteriosclerosis obliterans (ASO)
13. Cardiomyopathies
a. Congestive (dilated)
b. Restrictive
c. Hypertrophic cardiomyopathy
d. Postpartum
14. Pericardial disease
15. Infection-related
a. Viral myocarditis
b. Subacute bacterial endocarditis
c. Kawasaki’s
16. Other cardiac disorders
a. Immunologic
Acute rheumatic fever
Autoimmune disorders
b. Psychogenic
c. Traumatic
d. Nutritional
e. Tumor (emphasis on left atrial myxoma)
f. Thyroid dysfunction
g. Marfan syndrome
h. Drug-related such as cocaine, steroids and chemotherapeutic agents
17. Evaluation of cardiac patient for non-cardiac surgery
a. Cardiac risk
b. Preoperative and postoperative management
18. Antibiotic prophylaxis for valvular disease
a. Prevention of rheumatic carditis and its recurrence
b. Prevention of infective endocarditis, valvular heart disease and necessity for use of shunts
J. Cardiovascular pharmacology
SKILLS
The resident will demonstrate counseling and preparation of the patient for and performance of the following:
A. Diagnostic
1. Performance of history taking and physical examination
2. Mechanics and interpretation of ECG
3. Interpretation of chest radiographs
4. Stress-test interpretation
5. Ambulatory ECG interpretation
B. Therapeutic
1. Cardiopulmonary resuscitation (CPR), both basic and advanced
2. Acute treatment and chronic management of arrhythmias and conduction disturbances
3. Management of acute myocardial infarction and post infarction care
a. Use of thrombolytics
b. Use of anticoagulants
c. Use of antiarrhythmics
d. Complications of myocardial infarction
4. Acute treatment and chronic management of heart failure
5. Management of hypertensive emergencies
6. Supervision and management of rehabilitation
7. Counseling, education, and management of Psychological issues
a. Sexual
b. Depression
c. Family dynamics
9. Initial treatment and chronic management of patients after an intervention
a. Coronary bypass surgery
b. Valve surgery
c. Congenital heart disease surgery
d. Catheter interventional procedures
PATIENT CARE
· At the PGY1 level, residents will be expected to demonstrate skills in data gathering and organization, basic medical knowledge, clinical insight, and critical thinking. At the conclusion of this year, residents will be expected to have acquired enough skills to prioritize clinical problems, assume a team leadership role, and institute initial management of common acute clinical conditions.
· At the PGY2 and PGY3 levels, residents will be expected to make some independent decisions based on previous clinical experiences. Residents will be expected to demonstrate the ability to recognize and manage clinical scenarios not previously encountered and institute initial management of most acute clinical conditions, including prompt consultation and appropriate co-management when indicated. They will also be expected to effectively supervise junior residents and medical students in the initial evaluation of patients and in the provision of daily patient care in order to maximize patient safety and educational opportunities.
· At the PGY3 level, residents will further demonstrate mastery of a large set of special skills and will demonstrate the ability to practice independently.
Procedures
· EKG interpretation
· Placement of vascular access, including peripheral venous, central venous and radial arterial lines
· Lumbar puncture
· Paracentesis
· Interpretation of chest radiographs
· Joint aspiration and injection
MEDICAL KNOWLEDGE
1. Unstable Angina/acute coronary syndrome
2. Heart failure: Systolic, diastolic, right sided, cor pulmonale
3. Endocarditis
4. Valvular and rheumatic heart disease
5. Atrial Fibrillation
6. Hypertensive Emergencies
7. Acute M.I and common complications
1. Dìabetic Ketoacidosis and Hyperosmotic Nonketotic Hyperglycemia
2. Hospitalized patients with diabetes
3. Thyroid Disease
4. Adrenal Disease
Pulmonology
1. Asthma/COPD exacerbations
2. Community acquired pneumonia
3. Hospital acquired pneumonia
4. Obstructive sleep apnea
5. Pulmonary hypertension
Hematology/Oncology
1. Anemia
2. Neutropenia, thrombocytopenia and pancytopenia
3. Coagulopathies
4. Management of warfarin and heparin therapy
5. Sickle cell crisis
6. HIV/AIDS: acute presentation, common complications, antiviral therapy
1. Cirrhosis and liver failure
2. Hepatitis and jaundice
3. Upper and lower gastrointestinal bleeding
4. Pancreatitis
5. Biliary disease
6. Inflammatory bowel disease
7. Diverticulitis
1. Principles of antibiotic Use
2. Sepsis
3. Cellulitits and osteomyelitis
4. Tuberculosis
1. Anaphylaxis
2. Asthma
1. Altered mental status and delirium
2. Dementia
3. Stroke and TIA
4. Meningitis
5. Seizure and status epilepticus
6. Syncope
1. Thromboembolic disease (DVT, PE)
2. Arterial and venous insufficiency
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents will:
· Discuss common legal and ethical issues in the care of their panel of hospitalized patients
· Explore professional stresses common in the care of acutely ill patients and their families, and describe skills and resources that help diminish these stresses
· Participate in the collection, reporting, and review of adverse events in conjunction with the Inpatient Service Practice Improvement and Patient Safety programs
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Plan and conduct family meetings
· Discuss advanced directives sensitively with patients and their families
· Communicate promptly and effectively with consultants to collaborate in the care of and co-management of patients
· Demonstrate team leadership and supervisory skills
· Provide constructive feedback to fellow residents and to attending physicians
PROFESSIONALISM
Residents will:
· Demonstrate collegial and respectful relationships with team members and ancillary staff
· Demonstrate respectful and compassionate care of patients and their families
· Seek guidance from mentors or supervisors in the event of stressful situations or strained interactions with colleagues, team members or ancillary staff
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate consultation and/or expert assistance
· Formulate a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of consultants in relationship to primary care and collaborate with consultants in the care of patients
· Manage and coordinate psychosocial and family issues, including discharge planning, long-term care and use of community resources
WEB RESOURCES:
·CDC Immunization Schedule, 2006: http://www.immunize.org/cdc/child-schedule.pdf
· The Red Book (Report of the committee on infectious diseases): http://online.statref.com/TOC/TOC.aspx?FxId=76&SessionId=889E0BYRBVWWEZSH
· Johns Hopkins: The Harriet Lane Handbook:
· http://home.mdconsult.com/das/book/66010066-2/view/1304
PATIENT CARE
Family Medicine residents are expected to
· Develop knowledge and skills necessary to manage the medical, physical, social and emotional problems of infants, children and adolescents.
· Provide care for infants, children and adolescents in the context of the family.
· Monitor the development of each child to help realize his/her full potential, and to improve the health of children and families in the community in a proactive and responsive manner.
· Promote healthy lifestyles in children and families.
· Recognize the impact of social, cultural and environmental factors that affect the health and well-being of infants and children.
PGY1:
At the PGY1 level, residents will be expected to demonstrate skills in data gathering and organization, basic medical knowledge, clinical insight, and critical thinking. At the conclusion of this year, residents will be expected to have acquired enough skills to prioritize clinical problems, assume a team leadership role, and institute initial management of common acute clinical conditions.
PGY2, PGY3:
At the PGY2 and PGY3 levels, residents will be expected to make some independent decisions based on previous clinical experiences. Residents will be expected to demonstrate the ability to recognize and manage clinical scenarios not previously encountered and institute initial management of most acute clinical conditions, including prompt consultation and appropriate co-management when indicated. They will also be expected to effectively supervise junior residents and medical students in the initial evaluation of patients and in the provision of daily patient care in order to maximize patient safety and educational opportunities.
At the PGY3 level, residents will further demonstrate mastery of a large set of special skills and will demonstrate the ability to practice independently.
Procedures:
· Performance of specific procedures and interpretation of results
o APGAR scores assignation
o Developmental screening tests
o Behavior questionnaires for parent/teacher assessment of attention/deficit problems
o Hearing and vision screening tests
· Performance of and documentation age-appropriate history and physical examination, including use of growth charts
· Resuscitation of newborns, infants and children
· Calculation of maintenance and replacement fluid and electrolyte requirements
· Urethral catherization
· Blood draw
· Placement of intravenous line
· Arterial blood gas
· Lumbar puncture
MEDICAL KNOWLEDGE
Pediatric Inpatient (PGY1)
Residents will be expected to evaluate and initially manage:
Nursery (PGY1)
Residents will be expected to evaluate and initially manage conditions common to the fetal and neonatal period:
Pediatric Urgent Care, FHC Urgent Care and FHC Continuity Care (PGY1, PGY2, PGY3)
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents will:
· Discuss common legal and ethical issues in the care of infants, children and adolescents
· Review their individual practice registries and ensure that infants, children and adolescents in their care receive indicated screening and preventive interventions
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Plan and conduct family appointments and family meetings
· Communicate promptly and effectively with consultants to collaborate in the care of and co-management of patients
· Demonstrate team leadership and supervisory skills
· Provide constructive feedback to fellow residents and to attending physicians
PROFESSIONALISM
Residents will:
· Demonstrate collegial and respectful relationships with team members and ancillary staff
· Demonstrate respectful and compassionate care of patients and their families
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate consultation and/or expert assistance
· Formulate a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of consultants in relationship to primary care and collaborate with consultants in the care of infants, children and adolescents
· Manage and coordinate psychosocial and family issues, including hospitalization, discharge planning, and use of community resources
WEB RESOURCES
The UCSF Academic Geriatric Resource Center Online Curriculum: http://www.ucsfagrc.org/content.html
PATIENT CARE
Family Medicine residents are expected to
· Develop knowledge and skills necessary to manage the medical, physical, social and emotional problems of older adults.
· Provide care for elderly persons in the context of the family.
· Assist elderly persons to function independently with self-respect,
· Develop a comprehensive approach to the psychosocial and economic factors affecting the aging patient as well as the patient's family
· Obtain a comprehensive history and mental status examination, utilizing all available sources of information.
· Conduct an efficient comprehensive physical examination in office, hospital and nursing-home settings, mindful of the patient's modesty and mobility.
· Provide care for elderly patients, including healthy elderly patients and those with minor health problems, the chronically ill, the critically ill, the acutely ill and the injured.
· Provide continuity of care, including the ambulatory setting, the home, the hospital and the skilled nursing facility
PGY1:
PGY2, PGY3:
MEDICAL KNOWLEDGE
The resident will be expected to
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents are expected to:
INTERPERSONAL AND COMMUNICATION SKILLS
Residents are expected to:
· Counsel patients and their families about psychologic, social and physical stresses and changes of age, dying and death
PROFESSIONALISM
Residents are expected to:
· Set appropriate priorities and limitations for investigation and treatment.
SYSTEMS-BASED PRACTICE
Residents are expected to:
· Integrate an inter-disciplinary approach to the enhancement of individualized care.
Please note specific documentation requirements listed in red: use E-Value to enter this documentation so that your advisor and the program director can verify your experience.
PATIENT CARE AND MEDICAL KNOWLEDGE
Family Medicine residents will:
· Identify, evaluate, and initiate management of common acute surgical conditions
· Develop a systematic approach to the evaluation of acute and chronic symptoms in order to assess the need for surgical treatment and appropriate referral
PGY1:
Emergency Department rotation, Family Medicine Inpatient and Pediatric Inpatient rotations: acute presentation of common of surgical conditions
FHC: common office based surgical procedures
PGY2:
Surgical rotations: preoperative, intra operative, and post operative care of patients with a wide range of surgical conditions
PGY2, PGY3:
Acute care in FHC and Family Medicine Inpatient rotation: acute presentation of common surgical conditions
Continuity Practice: management and referral of patients with common surgical conditions, including preoperative evaluation and post operative follow-up
FHC: common office based surgical procedures
Procedures
· Preoperative assessment
(Guideline in the “George Book:” http://www.ucsf.edu/fhc/GBook_Frameset.htm
1. Identify appropriate surgical candidates
2. Assess surgical risk
Physical assessment
Radiographic assessment
Noninvasive diagnostic procedures
Invasive diagnostic procedures: e.g. biopsy, paracentesis
3. Identify and maximally manage co-existing conditions
4. Assess need for antibiotic prophylaxis
5. Prepare patient (bowel, etc.)
Document a minimum of 5 preoperative assessments.
Submit 2 preoperative assessments for your portfolio; these can be drawn from your surgery rotation, your continuity patient panel, or your FM inpatient service rotation
· Intraoperative care
(See Primary Care Procedures: http://www.primarycareprocedures.com/
1. Describe basic principles of asepsis and sterile technique
2. Discuss patient monitoring and principles of fluid management and replacement
3. Use basic surgical instruments
4. Prepare and drape operative field
5. Assist the primary surgeon, e.g. incision, dissection, exposure, retraction, and hemostasis
6. Estimate amount of blood loss
7. Describe wound closure
a. Technique selection (ligature, staples, adhesives)
b. Suture selection
c. Drains
d. Dressings
Document attendance at a minimum of 14 surgical procedures during your surgery rotation, at least one each from the following surgical categories: gynecology, urology, breast, abdomen, head and neck.
Document the indications for each procedure and any complications.
· Postoperative care
The resident will be able to describe the initial management of
1. Routine postoperative care
a. Wound care, dressing changes, and suture removal
b. Patient mobilization
c. Nutritional management
d. Pain
e. Suctions and drains, including time course for removal
2. Common postoperative complications
a. Fever
b. Wound dehiscence
c. Urinary retention
d. Hemorrhage
e. Pneumonia
f. Atelectasis
g. Fluid overload
h. Transfusion reaction
i. Thrombophlebitis
j. Pulmonary embolism
k. Oliguria
l. Respiratory insufficiency
m. Ileus
n. Infection
o. Shock
Document a minimum of 5 post-operative evaluations, including any complications; these can be drawn from your surgery rotation, your continuity patient panel, or your FM inpatient service rotation.
· Office procedures (*=optional)
(See Primary Care Procedures: http://www.primarycareprocedures.com/)
1. Local anesthesia
2. Simple excision
3. Simple lacerations
3. Incision and drainage of cysts and abscesses
4. Joint aspiration
6. Foreign body removal
7. Minor burns
8. Vasectomy*
9. Cauterization/electrodesiccation
10. Punch biopsy
11. Wound debridement
12. Enucleation/excision of external thrombotic hemorrhoid*
13. Nail surgery*
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents will:
· Discuss common legal and ethical issues in the care of surgical patients
· Participate in continuity of care of surgical patients
· Differentiate expected post surgical recovery from a course complicated by procedural, systemic, or patient factors
· Utilize their clinical experience in continuity to analyze these factors and formulate practices that might improve outcomes
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Document informed consent and complete procedure/operative notes
· Discuss potential risks and benefits with patients and families, using words that patients will understand and in collaboration with a medical interpreter when necessary
· Discuss advanced directives sensitively with patients and their families
· Communicate promptly and effectively with surgical consultants to collaborate in the care of, decision making, and co-management of patients
PROFESSIONALISM
Residents will:
· Demonstrate collegial and respectful relationships with team members and ancillary staff
· Demonstrate respectful and compassionate care of patients and their families
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate surgical consultation
· Formulate a plan of management, investigation and need for surgical consultation with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of surgical consultants in relationship to primary care and collaborate with consultants in the care of patients
· Manage and coordinate psychosocial and family issues, including discharge planning, long-term care and use of community resources
GOAL
To learn principles and skills in providing care of patients and families with chronic illness.
OBJECTIVES
To be able to assess the patients’ views of chronic illness
· What do patients think caused their illness?
· What do patients worry about most regarding their illness?
· What do patients think will improve their illness?
· How does a patient’s chronic illness affect their close relationships (e.g., family, friends, work, school)?
· How have their close relationships affected their chronic illness?
· Do family members share or differ from the patient in their view of the chronic illness?
To be able to assess the functioning of the patient-physician relationship and make
· improvements when necessary in the context of chronic illness
· What do patients want from their physician?
· What do physicians expect of patients and themselves in their work together?
· What are physicians’ beliefs and values about chronically ill patients and families?
WEB RESOURCES
· University of Michigan: The Eyes Have It http://www.kellogg.umich.edu/theeyeshaveit/index.html
· National Eye Institute: http://www.nei.nih.gov
PATIENT CARE
Family Medicine residents will be expected to:
· Identify, evaluate, and manage common ophthalmologic conditions
· Recognize the impact of ocular illness and dysfunction and
· Develop a systematic approach to the evaluation of symptoms in order to assess the need for treatment and appropriate referral
PGY1:
Emergency Department rotation and Pediatric Urgent Care rotation: common acute presentation of ocular symptoms
PGY2, PGY3:
Acute care in FHC: common acute presentation of ocular symptoms
Continuity Practice: management of and appropriate referral for screening and treatment of ophthalmologic complications of common chronic illnesses, such as diabetes and hypertension, and of common conditions of the eye, such as cataracts
PGY3:
Clinical experience in Ophthalmology: pre-operative evaluation, operative indications, and normal post-operative course for common ophthalmologic surgical procedures
Procedures
· Performance of specific procedures and interpretation of results
o Tests of visual acuity, visual fields, and test for ocular motility
o Direct ophthalmoscopy
o Flashlight examinations
o Fluorescein staining of the cornea
· Performance of physical examination in patients from newborns to adults, with emphasis on understanding normal neurologic and motor responses as well as appearance
· Using the clinical exam to localize the problem and generate the differential diagnosis and management planning
MEDICAL KNOWLEDGE
Review the following topics in the UMich Website (http://www.kellogg.umich.edu/theeyeshaveit/index.html)
Required:
· Principal Ophthalmic Conditions
· Ophthalmic Side-Effects of Systemic Medications
Optional:
· Anatomy of the Visual System
· Manifestations of Congenital-Hereditary Systemic Diseases
PROFESSIONALISM
· Residents will approach the care of the patient with ocular disease in a supportive and compassionate manner, especially in the case of someone with deteriorating vision
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate expert assistance
· Formulate a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of the ophthalmic consultant, including identifying the different roles of ophthalmologists, optometrists, and opticians
· Manage and coordinate of psychosocial and family issues, including long-term care of debilitating ocular conditions, necessary environmental adaptation and use of community resources
PRACTICE-BASED LEARNING
· Residents will review their individual diabetes practice registries and ensure that patients have adequate screening ophthalmologic screening and treatment
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Express concern for and support of patients and their families about the effects of loss of visual function
· Express to patients and families the importance of the role of support systems in the health of patients with ocular disease
MEDICAL KNOWLEDGE
The resident will be able to discuss the definition, diagnosis, and initial management of the following:
A. Basic components of dermatology
1. Normal anatomy, development and physiology
2. Risk factors
a. Congenital
b. Acquired
c. Aging
3. Prevention
a. Patient education
b. Compliance
4. Diagnostic guidelines
a. Arrangement, distribution, type and pattern of lesions
b. Type of lesion: primary/ secondary; macular/papular/ vesicular/nodular; tumor
c. Specific lesion sites
d. Seasonal variation/onset
5. Therapeutic considerations
6. Systemic evaluation (if indicated)
B. Common dermatologic problems
1. Skin problems
a. Papulosquamous disease
1. Seborrhea and dandruff
2. Psoriasis
3. Pityriasis rosea
4. Miliaria (prickly heat)
5. Lichen planus
b. Vesiculobullous diseases
1. Impetigo
2. Herpes simplex
3. Herpes zoster
4. Varicella
5. Pemphigoid
6. Pemphigus
7. Dyshidrosis
8. Erythema multiforme
9. Dermatitis herpetiformis
10. Epidermal necrolysis
11. Epidermolysis bullosa
c. Dermatitis
1. Contact
2. Atopic
3. Generalized exfoliative
4. Nummular
5. Stasis
6. Diaper rash
d. Macular eruptions
1. Viral exanthems
2. Drug reactions
e. Urticarial eruptions
1. Urticaria
2. Dermographism
f. Nodules
1. Erythema nodosum
2. Dermatofibroma
3. Granuloma annulare
4. Sarcoid
5. Cysts
g. Other pruritic conditions
1. Generalized
i. Scabies
ii. Dry skin (asteatosis)
iii. Secondary systemic disease
2. Localized
i. Lichen simplex chronicus (localized neurodermatitis)
ii. Pruritus ani
iii. Pediculosis (lice)
iv. Chigger and other insect bites
h. Cutaneous infections
1. Bacterial
i. Impetigo
ii. Erysipelas
iii. Lymphangitis
iv. Cellulitis
v. Boil (e.g., furuncle, pustule, folliculitis, abscess, carbuncle, ecthyma)
vi. Erythrasma
2. Mycobacterial
i. Atypical mycobacteria
3. Fungal
i. Superficial fungal infections
ii. Deep fungal infections
4. Viral
i. Herpes simplex
ii. Herpes zoster
iii. Warts
iv. Molluscum contagiosum
5. Rickettsial
i. Lyme disease
ii. Rocky Mountain spotted fever
i. Complexion and cosmetic problems
1. Acne vulgaris
2. Acne rosacea
3. Oily skin
4. Enlarged pores
5. Milia
6. Vascular lesions
7. Wrinkles
8. Keloid
9. Hyperhidrosis
j. Cutaneous injuries
1. Burns
i. Thermal
ii. Chemical
iii. Sunburn
2. Blister
3. Abrasion
4. Laceration
5. Bruise
i. Trauma
ii. Spontaneous purpura
6. Bites and stings
k. Pigment disorders
1. Hyperpigmentation
2. Hypopigmentation
i. Pityriasis alba
ii. Vitiligo
3. Tinea versicolor
l. New growths
1. Benign
a. Inflammatory lesions
i. Acne cyst
ii. Boil
iii. Hidradenitis
iv. Pyogenic granuloma
b. Hyperplasia
i. Verruca (common, plantar, anogenital, flat)
ii. Molluscum contagiosum
iii. Corn and callus
iv. Epidermal cyst
v. Skin tag (acrochordon)
vi. Xanthelasma
c. Neoplasia
i. Seborrheic keratosis
ii. Mole, nevus (intradermal, junctional)
iii. Compound, halo, blue, congenital)
iv. Lipoma
v. Dermatofibroma
vi. Keloid
vii. Hemangioma
viii. Neurofibroma
ix. Other, such as fibroma, leiomyoma
2. Premalignant
. Squamous cell carcinoma in situ (Bowen's disease)
a. Actinic keratosis
b. Disseminated superficial actinic porokeratosis
c. Leukoplakia
d. Keratoacanthoma
e. Erythroplakia
f. Premelanoma
i. Lentigo maligna
ii. Giant congenital nevus
iii. Dysplastic nevus syndrome
g. Radiation effects
3. Malignant
. Basal cell carcinoma
a. Squamous cell carcinoma
b. Melanoma
i. Major clinical categories
ii. Prognostic and therapeutic guidelines
c. Paget's disease
d. Cutaneous lymphoma
e. Kaposi's sarcoma
f. Metastases to the skin
m. Cutaneous manifestations of systemic disease, including human immunodeficiency virus infection and syphilis
n. Occupational skin disease
1. Hair problems
. Fungal infection
a. Nonscarring alopecia
i. Androgenetic (male pattern)
ii. Alopecia areata/ totalis/universalis
iii. Telogen effluvium
iv. Traction alopecia and trichotillomania
v. Endocrine effects
vi. Discoid lupus erythematosus
vii. Lichen planopilaris
b. Ingrown hair (pseudofolliculitis)
c. Hypertrichosis
i. Localized
ii. Virilizing causes of hirsutism
d. Texture alterations (hair dystrophy)
2. Nail problems
. Trauma
a. Disturbances associated with other dermatoses
b. Disturbances associated with systemic illness
c. Texture alteration
d. Fungal infection
e. Periungual and subungual conditions
i. Ingrown nail
ii. Paronychia
iii. Hematoma
f. Colored nails
g. New growths
h. Benign
i. Inflammatory
ii. Neoplasia
i. Malignant
1. Melanoma
2. Squamous cell carcinoma
3. Mucous membrane lesions
4. Oral lesions
. Thrush
a. Mouth ulcers
b. Sicca
c. Oral hairy leukoplakia
d. Geographic tongue
e. Black hairy tongue
f. Leukoplakia
g. Cheilitis
h. Lichen planus
The resident will demonstrate counseling and preparation of the patient for and performance of the following:
A. Diagnostic skills
1. Performance of history and physical examination with differential diagnosis
2. Acquisition, examination and interpretation of laboratory specimens
a. Biopsy
b. Culture
c. Scraping
3. Skin testing techniques and interpretation
4. Use of mechanical devices (i.e., Wood's light)
5. Systemic evaluation (if indicated)
6. Description of distribution and character of lesions
B. Management skills
1. Genetic counseling
2. Nutrition counseling
3. Preventive care
a. Routine skin care
b. Avoidance of environmental causes
c. Sunscreens
d. Appropriate use of over-the-counter lotions
4. Health promotion
5. Patient education
6. Use of photographs to document progress
7. Use of scales/indexes to grade disease severity
8. Use of consultations and referrals
C. Therapeutic skills
1. Medical
a. Topical
b. Systemic
2. Surgical
a. Cauterization of skin lesions
1. Acid cautery
2. Electrocautery
3. Electrodesiccation and curettage
b. Cryosurgery
c. Punch biopsy
d. Excision of skin lesions
e. Intralesional injection of corticosteroids
f. Incision and drainage
g. Treatment of ingrown toenails
3. Physical
a. Principles of ultraviolet light therapy
During the Intensive Care Unit rotation, PGY2 residents are expected to demonstrate skills in data gathering and organization using an organ systems approach, basic medical knowledge, clinical insight and critical thinking and to apply these skills in the care of critically ill adult patients.
PATIENT CARE
Residents will document management of a minimum of 15 patients during this rotation. Use E*Value to document the patient’s gender, age, and primary diagnosis.
Procedures
· Airway management, ventilatory support, and mechanical ventilation
· Respiratory therapy, including endotracheal suctioning, and nebulized therapy
· Arterial line insertion and interpretation of blood gases
· Central line placement
· Interpretation of data from hemodynamic monitoring
· Interpretation of chest radiographs
· Interpretation of laboratory tests
MEDICAL KNOWLEDGE
Residents will be able to discuss the pathophysiology, differential diagnosis and initial management of the following:
A. Cardiology
1. Hypertensive Emergency
2. Myocardial Infarction
3. Pericarditis
4. Dysrrhythmias
5. Hemodynamic instability, including appropriate monitoring techniques and vasoactive drugs
B. Endocrinology
1. Diabetic ketoacidosis
2. Nonketotic hyperosmolar syndrome
3. Adrenal insufficiency
4. Thyroid disorders
C. Pulmonology
1. Acute respiratory failure
a. Status asthmaticus
b. COPD
c. Obstruction
d. ARDS
e. Pulmonary edema
f. Pulmonary embolism
D. Hematology/Oncology
1. Disseminated intravascular coagulation
2. Coagulopathies
3. Blood product transfusions
E. Gastroenterology
1. Acute GI bleeding
2. Hepatic failure
3. Acute pancreatitis
F. Infectious Diseases
1. Community acquired pneumonia
2. Pneumonia in the immunocompromised host
3. Nosocomial pneumonia
4. Ventilator associated pneumonia
5. Sepsis
6. Meningitis
7. Endocarditis
8. Tuberculosis
9. Systemic fungal infections
G. Neurology
1. Coma
2. Delirium
3. Status epilepticus
4. Acute stroke
H. Nephrology
1. Acute renal failure
2. Emergent indications for hemodialysis (HD, CVVH)
3. Acid-base disturbances
4. Electrolyte disturbances
I. Nutritional
1. Enteral feeding
2. TPN
3. PPN
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents will:
· Discuss common legal and ethical issues in the care of critically ill patients
· Discuss essential aspects of advance directives and Durable Power of Attorney (DPOA) for health care
· Discuss issues common to care level transitions and end-of-life
· Attend and participate in ICU Morbidity and Mortality conferences and teaching conferences
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Plan and conduct family meetings
· Discuss advance directives sensitively with patients and their families
· Communicate promptly and effectively with consultants to collaborate in the care of and co-management of patients
PROFESSIONALISM
Residents will:
· Demonstrate collegial and respectful relationships with team members and ancillary staff
· Demonstrate respectful and compassionate care of patients and their families
· Seek guidance from mentors or supervisors in the event of stressful situations, or strained interactions with colleagues, team members and ancillary staff
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate expert assistance
· Formulate a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Manage and coordinate psychosocial and family issues
KNOWLEDGE AND SKILLS
The resident will be able to provide care from a systems approach to family practice. Specifically, residents will be able to:
1. Identify positive and problematic patterns of interaction in physician-patient relationships
2. Improve physician-patient relationships when necessary
3. Identify important patterns of interaction in patients’ intrapersonal and interpersonal relationships that relate to their health and illness
4. Understand the patients' health and illness in the context of their intrapersonal and interpersonal relationships
5. Identify and utilize patient/family strengths in treatment
6. Intervene in patients' intrapersonal and interpersonal relationships to address issues of their health and illness (e.g., reframing, tasks)
7. Articulate his/her beliefs and values that affect clinical work
The primary goal of the faculty/resident linkage curriculum (“linkage”) is to improve outpatient education for PGY2 and PGY3 residents. The concepts are essentially the same as those of PGY1 resident outpatient supervision and should be viewed as a continuation of this process. The basic elements include clinical consultation, direct observation, chart review, and practice management.
Linkage will also improve the continuity of patient management. Linkage faculty members will become familiar with resident practices and offer consistent clinical oversight. Residents are encouraged to consult with their linkage preceptors on all complex patient care issues.
Linkage preceptors will be scheduled for attend during the same clinic session each week. Each preceptor will be assigned a group of residents to supervise. Residents will be scheduled in clinical fort the same session each week, as their schedules allow. Linkage residents will consult exclusively with the linkage preceptor during these linkage sessions. The linkage preceptor may consult with other residents, but the consultation with the linkage residents should have first priority. Whenever possible, the linkage preceptor will not be 'doctor of the day.'
GOALS
Goals of the linkage curriculum include:
§ Continuity of patient management: residents are encouraged to schedule complex patients during their linkage clinics. Preceptors will make themselves available to consult on cases outside the scheduled linkage sessions.
§ Direct observation: Linkage residents will have access to the observation rooms on the Red and Gold Teams. Preceptors are expected to observe resident clinical sessions at least three times per year. Feedback on sessions will cover patient care and practice management. A review form will be completed for each observation session and a copy given to the resident and to the residency director.
§ Chart review: Linkage preceptors are expected to review resident notes. A minimum of one follow-up, and all new patient charts should be reviewed after each session. Residents should leave the yellow copies of notes for review in the preceptor's mailbox. A chart review feedback form should be completed for each note or chart. Comprehensive chart review will also occur during period review session.
§ Review sessions: There will be two to four review session scheduled each year. Resident clinics will be limited to allow time to meet with linkage preceptors. Medical records may be ordered for comprehensive review during these sessions. It is not anticipated that review sessions for residents will occur as a group due to the complexities of the clinic schedule.
WEB-BASED RESOURCES
· Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed.: http://home.mdconsult.com/das/book/58698186-3/view/1007
· American Family Physician: http://www.aafp.org/afp/
· CHN-specific guidelines: from a CHN linked computer, link to “Treatment Guidelines”, then “Perinatal Site” and then the specific topic
PATIENT CARE
PGY1: Obstetrical rotation: Evaluation, diagnosis and management of common obstetrical conditions, including normal labor, vaginal delivery, and common complications
PGY2 and PGY3: Obstetrical rotation, Continuity practice, Family Medicine call duty: Evaluation, diagnosis and management of common obstetrical complications. Further development of procedural skills. Continuity of care including prenatal, intrapartum, and post partum.
Procedures (asterisks designate required procedures; numbers are procedures required for credentialing)
· Triage evaluations and presentations to attending*
· Labor and ante-partum admission history, physical exams, write-ups and presentations*
· Cervical exam for dilation, effacement, station, and presenting part*
· Sterile speculum exam for vaginal bleeding or evaluation for ruptured membranes*
· Limited obstetrical ultrasound examination (for presentation, amniotic fluid index, heart tones): 10*
· Labor induction (with oxytocin, Foley bulb, prostaglandins, etc): 10*
· Amniotomy (active rupture of fetal membranes): 10*
· Insertion of intrauterine pressure catheter: 10*
· Amnioinfusion*
· Placement of fetal scalp electrode: 10*
· Vaginal delivery: 40*
· Vaginal delivery, continuity patient: 10*
· Repair of first degree perineal laceration: 5*
· Repair of second degree perineal laceration: 10*
· Assistant at C-section
· Assistant at C-section, continuity patient
· Assistant at operative delivery (forceps, vacuum)
· Assistant at operative delivery (forceps, vacuum), continuity patient
· First trimester ultrasound for pregnancy dating: 20
MEDICAL KNOWLEDGE
· Maternal Physiology During Pregnancy; physiology of lactation
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 1; Chapters 3 and 5. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Prenatal Care
Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues; (AFP April 2005). http://www.aafp.org/afp/20050401/1307.pdf
Evidence-Based Prenatal Care: Part II. Third-Trimester Care and Prevention of Infectious Diseases; (AFP April 2005). http://www.aafp.org/afp/20050415/1555.pdf
CHN Guideline: CHN Outpatient Breastfeeding Guidelines
CHN Guideline: Ordering Obstetric Ultrasounds at SFGHMC
CHN Guideline: High Risk Obstetric Clinic Consult and Referral Policy
· Normal Labor and delivery
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 13. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Management of pain during labor and delivery
The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain Relief; (AFP September 2003). http://www.aafp.org/afp/20030915/1109.pdf
The Nature and Management of Labor Pain: Part II. Pharmacologic Pain Relief; (AFP September 2003). http://www.aafp.org/afp/20030915/1115.pdf
Cochrane Briefs: Effects of Discontinuing Epidurals in Late Labor; (AFP April 2005). http://www.aafp.org/afp/20050401/cochrane.html#c2
· Overview of fetal heart rate assessment
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 14. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Examination of the Placenta; (AFP Mar. 1998). http://www.aafp.org/afp/980301ap/yetter.html
Repair of Perineal Lacerations; (AAFP October 2003). http://www.aafp.org/afp/20031015/1585.pdf
· Abnormal labor: protraction and arrest disorders
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 13. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Malpresentations: Breech, face, brow and compound presentation
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 16. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Shoulder Dystocia
Shoulder Dystocia; (AFP April 2004). http://www.aafp.org/afp/20040401/1707.pdf
· Post Partum Hemorrhage
Preventing Postpartum Hemorrhage: Managing the Third Stage of Labor; (AFP March 2006). http://www.aafp.org/afp/20060315/1025.pdf
· Post-term pregnancy
Management of Pregnancy Beyond 40 Weeks' Gestation; (AFP May 2005). http://www.aafp.org/afp/20050515/1935.pdf
· Induction of Labor and cervical ripening
Methods for Cervical Ripening and Induction of Labor; (AFP May 2003). http://www.aafp.org/afp/20030515/2123.pdf
Vaginal Misoprostol for Cervical Ripening in Term Pregnancy; (AFP Feb. 2006). http://www.aafp.org/afp/20060201/fpin.html
· Amnioinfusion
Transcervical Amnioinfusion; (AFP Feb. 1998). http://www.aafp.org/afp/980201ap/weismill.html
· Trial of Labor After Cesarean Section
CHN Guideline: Birth Choices (VBAC) Form: English Spanish Chinese
· Postpartum Care
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 4; Chapter 21. http://home.mdconsult.com/das/book/58873595-2/view/1007
An Approach to the Postpartum Office Visit; (AFP December 2005). http://www.aafp.org/afp/20051215/2491.pdf
· Intrapartum and Postpartum Fever
Williams: Obsterics. 22nd ed. Copyright 2005. Chapter 31. http://www.accessmedicine.com/content.aspx?aID=729371
· Hypertension, Preeclampsia, and Eclampsia
Diagnosis and Management of Preeclampsia; (AFP December 2004). http://www.aafp.org/afp/20041215/2317.pdf
Sibai, BM. Diagnosis, Prevention, and Management of Eclampsia. Obstetrics & Gynecology 2005;105:402-410. http://www.greenjournal.org/cgi/reprint/105/2/402
· Gestational Diabetes Mellitus
Diabetes; Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 6; Chapter 32. http://home.mdconsult.com/das/book/58698186-3/view/1007
Management of Gestational Diabetes Mellitus; (AFP Nov. 2003). http://www.aafp.org/afp/20031101/1767.pdf
CHN guideline: Guidelines For Screening Diabetes in Pregnancy
· Antepartum Fetal Surveillance
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 12. http://home.mdconsult.com/das/book/58698186-3/view/1007
CHN Guideline: Antepartum Testing Guidelines
· Fetal growth restriction
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 25. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Infections in Pregnancy
Urinary Tract Infections
Chemoprophylaxis for prevention of neonatal GBS disease
Care of pregnant women with HIV-infection/AIDS
· Trauma in Pregnancy
Blunt Trauma in Pregnancy; (AFP Oct. 2004). http://www.aafp.org/afp/20041001/1303.pdf
· Preterm Labor/Preterm delivery and Preterm Premature Rupture of Membranes
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 23. http://home.mdconsult.com/das/book/58698186-3/view/1007
Preterm Premature Rupture of Membranes: Diagnosis and Management; (AFP Feb. 2006). http://www.aafp.org/afp/20060215/659.pdf
· Management of premature rupture of membranes at term
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 13. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Amniotic Fluid disorders: Polyhydramnios and Oligohydramnios
Williams: Obsterics. 22nd ed. Copyright 2005. Chapter 21. http://www.accessmedicine.com/content.aspx?aID=725687
· Dermatologic complications of pregnancy
Common Skin Conditions During Pregnancy; (AFP January 2007). http://www.aafp.org/afp/20070115/211.pdf
Photo quiz: http://www.aafp.org/afp/20051115/photo.html
Photo quiz: http://www.aafp.org/afp/20050401/photo.html
· Multiple Gestation
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 24. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Diagnosis and management of Rh alloimmunization
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 26. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Thyroid disease in pregnancy
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 6; Chapter 33. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Thromboembolic disease
Williams: Obsterics. 22nd ed. Copyright 2005. Chapter 47. http://www.accessmedicine.com/content.aspx?aID=736251
· Intrahepatic Cholestasis and Acute Fatty Liver of Pregnancy
Williams: Obsterics. 22nd ed. Copyright 2005. Chapter 50. http://www.accessmedicine.com/content.aspx?aID=737667
· Fetal teratogens/drugs in pregnancy
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 9. http://home.mdconsult.com/das/book/58698186-3/view/1007
· First Trimester Bleeding
Ultrasonography for First-Trimester Bleeding; (AFP Oct. 2005. http://www.aafp.org/afp/20051015/tips/14.html
Diagnosis and Management of Ectopic Pregnancy; (AFP Nov. 2005). http://www.aafp.org/afp/20051101/1707.pdf
Management of Spontaneous Abortion; (AFP Oct. 2005). http://www.aafp.org/afp/20051001/1243.pdf
· 2nd and 3rd Trimester Bleeding
Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Section 3; Chapter 17. http://home.mdconsult.com/das/book/58698186-3/view/1007
· Abnormal Cervical Cytology Screening in Pregnancy
Practice Guidelines: ACOG Releases Guidelines for Management of Abnormal Cervical Cytology and Histology; (AFP Feb. 2006). http://www.aafp.org/afp/20060215/practice.html#p1
CHN Guideline: Abnormal PAP Smear Guideline PDF
CHN Guideline: PAP Smear Screening for Cervical Cancer
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents are expected to:
· Utilize self-directed learning toward further knowledge and competence in obstetrics
· Participate actively in performance improvement and patient safety programs of the obstetrics and family medicine departments
INTERPERSONAL AND COMMUNICATION SKILLS
Residents are expected to:
· Document informed consent and complete procedure/operative notes
· Discuss potential risks and benefits with patients and families, using words that patients will understand and in collaboration with a medical interpreter when necessary
· Provide compassionate care to the obstetrical patient within the context of their family and social support systems
· Evaluate patients systematically and communicate presentations effectively to supervising residents, fellows and attendings
· Document their care of patients and interventions in a timely manner
PROFESSIONALISM
Residents are expected to :
· Demonstrate collegial and respectful relationships with team members and ancillary staff
· Demonstrate respectful and compassionate care of patients and their families
SYSTEMS-BASED PRACTICE
Residents are expected to:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate obstetrical consultation
· Formulate a plan of management, investigation and need for obstetrical consultation with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of obstetrical and perinatal consultants in relationship to primary care and collaborate with consultants in the care of patients
· Manage and coordinate psychosocial and family issues, including discharge planning, long-term care and use of community resources
MEDICAL KNOWLEDGE
The resident will be able to discuss the definition, diagnosis, and initial management of the following:
A. Normal anatomy and physiology
B. Normal growth and development
C. Musculoskeletal history taking
D. Principles of musculoskeletal physical examination
E. Laboratory data including indications, contraindications and interpretation (e.g. joint fluid)
F. Testing
1. Interpretation of common musculoskeletal radiographs
2. Appropriate use of magnetic resonance imaging, computed tomographic scanning and bone scanning
3. Procedures: indications and understanding of techniques
a. Arthrogram
b. Myelogram
c. Arthroscopy
G. Pathogenesis/pathophysiology/recognition
1. Joint pain, swelling and erythema
2. Muscular pain, swelling and injury
3. Musculoskeletal trauma
4. Fractures
5. Dislocations
6. Tendon injuries
7. Nerve injuries
8. Bone and joint deformities
9. Bone and joint infections
10. Metabolic bone diseases
11. Musculoskeletal congenital anomalies
12. Musculoskeletal birth injuries
13. Compartment syndrome
14. Avascular necrosis
15. Osteoporosis
16. Overuse syndromes
H. Pediatric problems
1. Hip dislocation
2. Congenital hip dysplasia
3. Legg Calvé-Perthes disease
4. Osgood-Schlatters disease
5. Slipped capitofemoral epiphysis
6. “Clubfoot” (talipes)
7. Intoeing (metatarsus adductus, tibial torsion, femoral anteversion)
8. “Bow leg” (genu varum) and “knock knee” (genu valgum)
9. Epiphyseal injuries in children according to the Salter-Harris classification
10. Transient synovitis
11. Child abuse
I. Management and therapy
1. Outline expected course with and without therapy
2. Patient education for acute and chronic problems
3. Pharmacologic treatment
a. Salicylates
b. Nonsteroidal anti-inflammatory agents, including cox-2 inhibitors
c. Steroids, oral and injectable
d. Muscle relaxants
e. Antibiotics
4. Supportive and corrective devices
a. Braces (thoraco-lumbar, knee)
b. Casts
c. Splints
d. Orthotics
5. Rehabilitation
a. Physical therapy
1. Cold, heat
2. Ultrasound
3. Exercises
4. Iontophoresis
b. Occupational therapy
c. Alternative modalities
d. Psychosocial aspects of trauma
6. Surgery
a. Internal and external fixation devices
b. Artificial joint replacement
J. Prevention
1. Pre-participation screening
2. Conditioning and training
3. Injury prevention
4. Physical fitness/Exercise Prescription
5. Bone loss
a. Nutrition
b. Exercise
c. Pharmacology
SKILLS
The resident will demonstrate counseling and preparation of the patient, including discussion of sequela, for the following:
A. Basic Care
1. Fractures (simple, stable, closed and nondisplaced)
a. Metacarpal, metatarsal, phalangeal
b. Forearm, single bone midshaft
c. Humerus, midshaft
d. Clavicle
e. Ribs
f. Vertebrae, lumbar or thoracic compression-type
g. Pelvis, excluding interruption of the pelvic ring
h. Patella
i. Lower leg, single bone midshaft
j. Unimalleolar ankle
k. Calcaneus
2. Sprains and strains
a. Finger
b. Toe
c. Ankle
d. Knee
e. Vertebral column
f. Wrist
g. Elbow
h. Shoulder
i. Neck
j. Muscular strains (e.g. hamstring, trapezius)
3. Other problems
a. Costochondritis
b. Bursitis/tendinitis/tenosynovitis
c. Elbow: “tennis”, “nursemaid”, “little-league”
d. Entrapment syndrome
e. Baker’s cyst
f. Chondromalacia patellae
g. Osgood-Schlatter disease
h. Osteochondroses/aseptic necrosis
i. Osteoarthritis/crystal-induced arthritis (e.g. gout/pseudo-gout)
j. Metabolic bone disease (osteoporosis, Paget’s disease)
k. Acute and chronic low back pain
l. Foot conditions
1. Halux Valgus (bunions)
2. Plantar Fasciitis
3. Mortons Neuroma
m. Osteomyelitis
n. Overuse syndromes
1. Shoulder impingement
2. Patellofemoral syndrome
o. Rheumatologic Disorders
4. Procedures (indications, contraindications and competency)
a. Joint aspiration (arthrocentesis)
b. Joint and musculoskeletal injection (local anesthesia, steroid)
c. Wrapping and taping
1. Elasticized bandage
2. Ankle taping
3. Clavicular figure-of-eight bandage
4. Soft cervical collar
d. Splints (upper and lower extremity)
e. Plaster and fiberglass casts
1. Short and long leg, with and without walker
2. Short and long arm
3. Thumb Spica
4. Cast wedging
5. Cast problems
f. Dislocation reduction
1. Simple anterior shoulder
2. Radial head
3. Simple posterior elbow
4. Phalanges
5. Patella
6. Mandible
g. Traction application (Buck’s, cervical)
B. Advanced care
1. Fractures
a. Closed tarsal and carpal bones, particularly navicular
b. Colles’ fracture
c. Nondisplaced medial or lateral epicondyle of humerus
d. Nondisplaced type I or type II epiphyseal injuries in children
e. Jones Fracture (proximal 5th metatarsal)
2. Meniscal tears
3. Recurrent dislocations (e.g. shoulder, patella)
C. Orthopedic Emergency Recognition and Stabilization
1. Compartment Syndrome
2. Hip Dislocation
3. Knee Dislocation
4. Pelvis Fracture
5. Cervical Spine Fracture
6. Cord Injury
D. Surgical Assisting
Please review the following educational objectives: Care of Hospitalized Adults and Cardiovascular Medicine.
A PGY2 or PGY3 resident is assigned to cover night duties on the inpatient service for a minimum of 2 weeks each academic year. The principal goal is to ensure the highest quality of patient care and patient safety, and to meet guidelines for resident duty hours.
Residents are expected to
· Make some independent decisions based on previous clinical experiences,
· Demonstrate the ability to recognize and manage clinical scenarios not previously encountered,
· Institute initial management of most acute clinical conditions, including prompt consultation and appropriate co-management when indicated, and
· Effectively supervise junior residents and medical students in the initial evaluation of patients and in the provision of daily patient care in order to maximize patient safety and educational opportunities.
The following objectives are emphasized during this rotation.
PATIENT CARE
Residents will:
· Gather relevant and accurate information about patients
· Perform thorough, systematic physical exams
· Formulate medically appropriate treatment plans
· Maintain continuity with their outpatient practice panels
MEDICAL KNOWLEDGE
Residents will appropriately manage cross-cover care.
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Present data clearly, systematically
· Attend and actively participate in morning reports
· Consult with chief residents, attendings, or other services in a timely and professional manner
· Communicate effectively with primary team
PROFESSIONALISM
Residents will participate in team work.
SYSTEMS-BASED PRACTICE
Residents will demonstrate good judgment by ordering diagnostic tests and interpreting them appropriately.
WEB RESOURCES
· AAO-HNS: ENT link http://www.entlink.net/education/primary-care.cfm
· University of Toronto: http://icarus.med.utoronto.ca/carr/manual/outline.html
PATIENT CARE
Family Medicine residents will be expected to:
· Identify, evaluate, and manage common ear, nose, and throat conditions
· Develop a systematic approach to the evaluation of symptoms in order to assess the need for treatment and appropriate referral
PGY1
Emergency Department rotation and Pediatric Urgent Care rotation: common acute presentation of ENT symptoms
PGY2, PGY3
Acute care in FHC: common acute presentation of ENT symptoms
Continuity Practice: management of and appropriate referral for screening and treatment of acute and chronic ENT conditions
PGY3
Clinical experience in ENT: pre-operative evaluation, operative indications, and normal post-operative course for common ENT surgical procedures
Procedures
· Performance of specific procedures and interpretation of results
o Weber and Rinne tests
o Tympanoscopy
o Screening audiometry
o Removal of impacted cerumen
o Anterior rhinoscopy (nasal speculum exam)
o Anterior nasal packing (for epistaxis)
o Oropharynx examination
o Nasal endoscopy
o Nasopharyngoscopy
o Facial nerve testing
· Performance of physical examination in patients from newborns to adults, with emphasis on understanding normal response and appearance
· Using the clinical exam to localize the problem and generate the differential diagnosis and management planning
MEDICAL KNOWLEDGE
· Review the following topics in the American Academy of Otolaryngology
(http://www.entlink.net/education/primary-care.cfm)
Required:
o Chapter 3: Postoperative Fevers
o Chapter 8: Facial Nerve Paralysis
o Chapter 9: Rhinology, Nasal Obstruction and Sinusitis
o Chapter 11: Maxillofacial Trauma
o Chapter 13: Salivary Gland Disease
o Chapter 14: Thyroid Cancer Thyroid
o Chapter 15: Head and Neck Cancer
o Chapter 17: Pediatric Otolaryngology
Optional:
o Chapter 10: How to Read a Sinus CT Scan
o Chapter 12: Facial Plastic Surgery
PRACTICE-BASED LEARNING AND IMPROVEMENT
· Residents will review evidence-based guidelines to improve their treatment of otitis, sinusitis and pharyngitis
INTERPERSONAL AND COMMUNICATION SKILLS
Residents will:
· Educate patients about the prevention and treatment of common ENT conditions
· Express concern for and support of patients and their families regarding the effects of hearing loss
· Express to patients and families the importance of the role of support systems in the health of patients with hearing loss
PROFESSIONALISM
· Residents will approach the care of the patient with ENT disease in a supportive and compassionate manner
SYSTEMS-BASED PRACTICE
Residents will:
· Formulate a rational plan of investigation and management, including assessment of severity and need for immediate expert assistance
· Formulate a plan of management, investigation and need for expert advice with an awareness of the risks and costs of the investigation and the value of the information that will be obtained
· Describe of the role of the ENT consultant
· Manage and coordinate of psychosocial and family issues, including long-term care of debilitating conditions, necessary environmental adaptation and use of community resources
WEB RESOURCE
Primary Care Procedures: http://www.primarycareprocedures.com
PATIENT CARE
Procedures
· Cryotherapy
· Endometrial Biopsy
· Excision of dermal or subdermal lesion requiring skin closure
· Joint injection and/or aspiration
· Skin Biopsy (punch biopsy or shave biopsy)
Residents are expected to:
· Prepare and maintain a sterile field
· Employ correct procedure technique
MEDICAL KNOWLEDGE
Residents are expected to:
· Describe indications and contraindications
· Review the following articles:
§ Regional Anesthesia for Office Procedures: Part I. Head and Neck Surgeries (AFP 2004); http://www.aafp.org/afp/20040201/585.pdf
§ Regional Anesthesia for Office Procedures: Part II. Extremity and Inguinal Area Surgeries (AFP 2004); http://www.aafp.org/afp/20040215/896.pdf
§ Common Benign Skin Tumors (AFP 2003); http://www.aafp.org/afp/20030215/729.pddf
§ Fusiform Excision (AFP 2003); http://www.aafp.org/afp/20030401/1539.pdf
§ Punch Biopsy of the Skin (AFP 2002); http://www.aafp.org/afp/20020315/1155.pdf
§ Cutaneous Warts: An Evidence-Based Approach to Therapy; http://www.aafp.org/afp/20050815/647.pdf
§ Dermal Electrosurgical Shave Excision (AFP 2002); http://www.aafp.org/afp/20020501/1883.pdf
§ Endometrial Biopsy (AFP 2001); http://www.aafp.org/afp/20010315/1131.pdf
§ Diagnostic and Therapeutic Injection of the Wrist and Hand Region (AFP 02/2003); http://www.aafp.org/afp/20030215/745.pdf
§ Knee Joint Aspiration and Injection (AFP 2002); http://www.aafp.org/afp/20021015/1497.pdf
§ Joint and Soft Tissue Injection (AFP 2002); http://www.aafp.org/afp/20020715/283.pdf
§ Diagnostic and Therapeutic Injection of the Hip and Knee (AFP 2003); http://www.aafp.org/afp/20030515/2147.pdf
§ Trigger Points: Diagnosis and Management (AFP 2002); http://www.aafp.org/afp/20020215/653.pdf
§ Office Management of Digital Mucous Cysts (AFP 2001); http://www.aafp.org/afp/20011215/1987.pdf
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents are expected to:
· Assimilate feedback during supervision and request a “Credentialing for Independent Performance of Procedures” evaluation after meeting minimum numbers documentation
· Use appropriate safety precautions when handling sharps and bodily fluids
INTERPERSONAL AND COMMUNICATION SKILLS
Residents are expected to:
· Describe aftercare and possible complications and their management
· Documents appropriate procedure note in patient’s record
PROFESSIONALISM
· Residents are expected to answer patients’ questions and validate their concerns
SYSTEMS-BASED PRACTICE
· Residents are expected to obtain informed consent, using words and language their patients understands and collaborating with medical interpreters when necessary