PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 17: PULMONARY MEDICINE
This section has been reviewed and approved by the Chief, Division of Pulmonary Medicine
as well as the Program Director, Internal Medicine Residency Program at Prince George’s
Hospital Center.
________________________
Chief, Division Of Pulmonology
______________________________
Program Director, Residency Program
I. Overview
Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper
airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in
neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura, and
airways; pulmonary vascular disease and its effect on the cardiovascular system; and
detection and prevention of occupational and environmental cause of lung disease.
Other specialized areas include respiratory failure and sleep-disordered breathing.
By the end of their training in internal medicine, residents should be able to evaluate and
manage cough, dyspnea, fever with infiltrates, mass or nodule on the chest radiograph,
pleurisy, and pleural effusion. He/she should be able to diagnose and manage patients
with common respiratory infections: initiate the diagnostic evaluation of respiratory
neoplasm; and manage the initial approach to patients with respiratory failure, including
those in intensive care units.
With more hospitalist jobs requiring interninsts to manage patients on ventilators on
medical floors or intensive care units, residents during their rotation should obtain a
working knowledge of this subject. The pulmonary specialist will usually assist internist
for diagnostic procedures and complicated conditions such as advanced respiratory
failure.
II. Principle Teaching Methods
This consists of frequent encounters with the medicine residents and making that person
accountable for performance. It primarily consists of bedside rounds conducted most
days of the week, a s well as in radiology. Here most of the teaching will be carried out.
The residents will also observe performance of pulmonary function tests in the PFT
laboratory and learn interpretation of the results. They will also observe special
procedures like bronchoscopies done on the patients that they are following. The
residents will also get a working knowledge of mechanical ventilators through rounds
and didactics focusing on management of hospitalized patients requiring ventilator
support.
The resident will have frequent interaction with their supervising attending and rounds
will include short 15-30 minute discussions on current medical topics driven by patient
encounters, initiated by the residents and completed by the attending physician on most
days of the week. Latest information dealing with the topic as provided by literature
search and pertinent articles made available to the residents.
During the rotation the residents will outpatient Pulmonary office practice three half days
a week with Dr. Murthy or Dr. Steinberg. Residents must print out a copy of the
‘Pulmonary Attendance Sheet’ from the end of this section and have it signed for each
outpatient day. The residents will also round with Dr. Boyce on hospitalized patients on
mechanical ventilation and learn about different ventilator modes and management of
patients and acute and chronic ventilation. Residents must have their attendance taken
during these rounds. The residents must submit their Attendance Sheet with the
program coordinator as a requirement for successful completion of the rotation
During the rotation the resident must also analyze a minimum number of diagnostic tests
with the staff pulmonologist. The logsheet at the end of this section lists the tests and
their minimum number they must interpret for the month. The residents are required to
view X Ray and CT films with the attending as well as interpret ABG and PFT results.
They are also required to review all Lung biopsy slides with the pulmonary attending
physician in pathology irrespective of whether the patient is on staff service or not. This
is to allow residents to review pathology report, learn indications for bronchoscopy and
lung biopsies as well as learn about the disease process of the particular case.
Residents must print a double-sided Pulmonary Logsheet and have it signed by the
attending as they complete each requirement. Residents must submit a completed copy
to the program coordinator to get credit for the rotation.
III. Strengths and Limitations
The residents will be exposed to a broad range of clinical problems typical of a
community-based practice with emphasis on inpatient illnesses and care. The teaching
faculty for the Department of Pulmonology will be committed to teaching and being a
strong role model to the residents. They will supervise the residents on consults,
interpreting results of radiographic and pulmonary function studies, bedside procedures
like thoracentesis, ventilator management and make residents familiar with indication of
special procedures like bronchoscopy, VATS.
For patients with unusual clinical problems the care may require transfer to tertiary
referral center. The residents are encouraged to gain outpatient experience in the
subject by shadowing the attending in their private office. Patients in the continuity clinic
at Glenridge also offer learning opportunities. The resident can also utilize the
opportunity to learn regarding cardiopulmonary rehabilitation from patients who are
status post cardiac bypass surgery.
IV. Goals and Objectives
Legend of Learning Activities
Learning Venues:
1. Direct patient care/ consultation
2. Attending rounds
3. Morning report and noon conference
4. Core lecture series
5. Self study
Evaluation methods
A.
B.
C.
D.
E.
Attending rounds on consult patients
Attending evaluation of PFT, ABG and radiologic interpretation skills
Direct Observation
Nurse’s evaluation
In-training examination
Competency: Patient Care
Interview patients more skillfully, gathers accurate and
essential information with emphasis on pulmonary
diseases
Examine patients more skillfully with competent and
complete observation of normal and abnormal signs
with emphasis on disorders of the pulmonary system
Define and prioritize patient’s medical problems
Generate and prioritize differential diagnoses with
appropriate testing and therapeutics
Develop rational, evidence-based management
strategies
Competency: Medical Knowledge
Expand clinically applicable knowledge base of the
basic and clinical sciences underlying the care of
medical service patients, both out and inpatients with
emphasis on pulmonary disorders.
Access and critically evaluate current medical
information and scientific evidence relevant to patient
care
Competency: Practice-Based Learning and
Improvement
Identify and acknowledge gaps in personal knowledge
and skills in the care of hospitalized and out patients
Develop and implement strategies for filling gaps in
knowledge and skills and minimize errors
Competency: Interpersonal Skills and
Communication
Communicate effectively with patients and families,
with particular emphasis on explanation of complex
and multi-system illness and the testing required to
confirm diagnostic possibilities
Communicate effectively with physician colleagues at
all levels with appropriate consultation when needed
Present patient information concisely and clearly,
verbally and in writing. Adhere to confidentiality
Competency: Professionalism
Learning Venues
1, 2, 3, 4
Evaluation Methods
A, B, C, D
1, 2, 3, 4
A, B, C, D
1, 2, 3, 4
1, 2, 3, 4
A, B, C, D
A, B, C, D
1, 2, 3, 4
A, B, C, D
Learning Venues
ALL
Evaluation Methods
A, B, C, E
ALL
A, B, C E
Learning Venues
Evaluation Methods
ALL
A, B, C, E
ALL, meet with
Program Director
Learning Venues
A, B, C, E , attendance
sheet
Evaluation Methods
1,2,3
A, B, C, D
1,2,3
A, C
1, 2
A, C
Learning Venues
Evaluation Methods
Demonstrate respect, compassion, integrity and
altruism towards patients, families, colleagues, and all
members of the health care team
Demonstrate sensitivity to confidentiality, gender, age,
cultural differences and disabilities
Competency: Systems-Based Practice
Understand and utilize the multidisciplinary resources
1,2,3
A, C, D
1,2,3
A,C,D
Learning Venues
ALL
Evaluation Methods
A,C,D
necessary to care optimally for hospitalized and out
patients and the limitations of various practice
environments.
Collaborate with other members of the health care
team to assure comprehensive patient care
Use evidence-based, cost-conscious strategies in the
care of hospitalized and outpatients
1,2
A,C,D
1,2,3,4
A,C,D
V. Educational Content
A. Airway Diseases
1) Diagnosis and management of:
 Asthma
 Bronchiectasis
 Bronchitis
 Chronic obstructive pulmonary disease
 Upper airway obstruction- initiate management
2) Order appropriate tests and interpret results of:
 Complete pulmonary function tests (spirometry, measurement of lung
volume, diffusing capacity, flow volume loop)
 Cardiopulmonary stress test
 Pre-operative pulmonary clearance in lung reduction surgery
B. Intensive care unit condition
1) Identify and initiate management of
 Acute Respiratory Distress Syndrome
 Ventilator associated Pneumonia
 Tension Pneumothorax
 Pulmonary embolism
 Pulmonary hypertension
2) Order appropriate tests and interpret results of:
 Swan ganz catheter reading
 Chest X Ray
 CT thorax
 Ventilation perfusion scan
 Arterial blood gases
C. Congenital Lung Disease
1) Understand the diagnostic criteria, long term complications and management of:
 Alpha1, antitrypsin deficiency
 Cystic fibrosis
 Dysmotile cilia syndrome
2) Criteria for transplantation
D. Infection
1) Diagnosis and initial management of
 Atypical mycobacteria
 Empyema
 Lung abscess

Pneumonia (Community-acquired, nosocomial, In
patient)
 Pulmonary mycoses
 Tuberculosis
2) Order and interpret results of:
 PPD in outpatient, inpatient and nursing home setting
 Sputum cultures and stains
 Chest X rays and other imaging studies
E. Interstitial Disease
 Collagen vascular disease
 Drug-induced
 Eosinophilic pneumonia
 Hypersensitivity
 Idiopathic pulmonary fibrosis
 Sarcoidosis
F. Neoplasm
1) Know the diagnostic work up and management of
 Lung cancer – all types
 Mediastinal mass
 Solitary pulmonary nodule
2) Know indications for ordering and interpreting results of:
 PET scan
 CT scan
 Chest x ray
 Bronchoscopy with FNA biopsy, BAL
 Cytology, pathology of lung and pleural biopsy specimens
 Diagnostic studies for venous thrombosis
 Mediastinoscopy, mediastinotomy
G. Occupational Disease
 Asbestos-related
 Occupational asthma
 Pneumoconiosis
H. Pleural Disease
 Malignant effusion
 Non-neoplastic pleural effusion
I.
Prevention
 Avoidance of respiratory irritants, allergens
 Immunization
 Pulmonary carcinogens (radon, passive smoking)
 Smoking cessation
J. Vascular Lung Disease
1) Understand the diagnosis and management of patients with:
 Pulmonary Hypertension
immunosuppressed
 Cor pulmonale
2) Understand the indications and interpreting results of
 2 D echocardiograms and TEE
3) Criteria for transplant and its complications
K. Sleep-disordered breathing
 Know indications and Interpretation of results of sleep study to diagnose
central and obstructive sleep apnea
 Appropriate management including interpretation of titration studies
VI. Recommended Readings
Residents are encouraged to read the Pulmonary section of the MKSAP during their
rotation as well as read articles using MDConsult and Up To Date on a case by case
basis. Other recommended readings are as follows:
A. COPD
1) Soto, FJ and Varkey B. Evidence-based approach to acute exacerbations of
COPD. Current Opinion in Pulmonary Medicine 9:117-124, 2003.
2) Sutherland ER and Cherniack R. Management of chronic obstructive pulmonary
disease. New England Journal of Medicine 350:2689-97, 2004.
B. Pneumonia
1) File TM. Community-acquired pneumonia. Lancet 362:1991-2001, 2003.
2) Niederman MS, Mandell LA, Anzueto A et al. Guidelines for the management of
adults with community-acquired pneumonia. Diagnosis, assessment of severity,
antimicrobial therapy, and prevention. American Journal of Respiratory and
Critical Care Medicine. 163(7):1730-1754, June 2001.
C. Asthma
1) Siwik JP, Nowak RM, and Zoratti EM. The evaluation and management of acute,
severe asthma. Medical Clinics of North America 86(5): 1049-71, 2002.
2) FitzGerald M. Acute Asthma (Extracts from "Clinical Evidence"). BMJ 323(7317):
841-5, October 13, 2001.
3) Mathur SK. Asthma: diagnosis and management. Med Clin North Am - 01-Jan2006; 90(1): 39-60
D. Pulmonary Function Tests
1) Crapo RO. Pulmonary-function testing. New England Journal of Medicine.331
(1): 25-30, July 7, 1994.
2) Celli BR. The importance of spirometry in COPD and asthma: Effect on approach
to management. Chest. 117(2 Suppl): 15S-19S, February 2000.
E. Thromboembolic Disease
1) Ramzi DW and Leeper K. DVT and pulmonary embolism: Diagnosis. American
Family Physician 69:2829-36, 2004.
2) Ramzi DW and Leeper K. DVT and pulmonary embolism: Treatment and
prevention. American Family Physician 69:2841-8, 2004.
3) Bauer KA. The thrombophilias: Well-defined risk factors with uncertain
therapeutic implications. Annals of Internal Medicine. 135(5): 367-73, September
4, 2001.
4) Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh
ACCP Conference on Antithrombotic and Thrombolytic Therapy. Harry R. Büller,
Giancarlo Agnelli, Russel D. Hull, Thomas M. Hyers, Martin H. Prins, and Gary E.
Raskob. Chest 126: 401S-428S.
F.
Pleural Disease
1) Light RW. Pleural effusion. NEJM. 346:1971-77, 2002.
2) Sahn SA, Heffner JE. Spontaneous pneumothorax. New England Journal of
Medicine. 342(12): 868-74, March 23, 2000.
3) Maskell N A and Butland R J A, BTS guidelines for the investigation of a
unilateral pleural effusion in adults. Thorax 2003; 58 (Suppl 2): ii8-ii17.
G. Interstitial Lung Disease/Sarcoidosis
1) Gross TJ, Hunninghake GW. Idiopathic pulmonary fibrosis. New England Journal
of Medicine. 345(7): 517-25, August 16, 2001.
2) Baughman RP, Lower EE, and duBois RM. Sarcoidosis. Lancet 361:1111-18,
2003.
3) Collard HR, King TJ, Demystifying Idiopathic Interstitial Pneumonia, Arch Intern
Med 2003; 163:17-29.
4) Baughman RP. Pulmonary Sarcoidosis. Clin Chest Med - 01-Sep-2004; 25(3):
521-30
H. Sleep Apnea
1) Masood A, Phillips B. Sleep apnea. Current Opinion in Pulmonary Medicine. 6(6):
479-84, November 2000.
2) Herer B, Roche N, Carton M et al. Value of clinical, functional, and oximetric data
for the prediction of obstructive sleep apnea in obese patients. Chest. 116(6):
1537-44, December 1999.
3) Strollo PJ Jr., Rogers RM, Obstructive sleep apnea. N Engl J Med. 1996 Jan 11;
334(2): 99-104.
I.
Tuberculosis
1) Small PM, Fujiwara PI. Management of tuberculosis in the United States. New
England Journal of Medicine. 345(3): 189-200, July 19, 2001.
2) Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide
for latent tuberculosis infection, and revisions in American Thoracic Society/CDC
recommendations--United States, 2001. Morbidity and Mortality Weekly Report.
50(34): 733-5, August 31, 2001.
J. Lung Transplantation
1) Arcasoy SM, Kotloff RM. Lung transplantation. New England Journal of Medicine.
340(14): 1081-91, April 8, 1999.
2) Levine SM, Angel LF. The patient who has undergone lung transplantation:
Implications for respiratory care. Respir Care. 2006 Apr; 51(4):392-402.
3) Alexander BD, Tapson VF. Infectious complications of lung transplantation.
Transplant Infectious Disease. Vol 3 (3) 128-137, Sep 2001
K. Diagnosing Lung Cancer
1) Ost D, Fein AM, Feinsilver SH, The Solitary Pulmonary Nodule, N Engl J Med
2003; 348:2535-42.
2) Hensing TA, Clinical evaluation and staging of patients who have lung cancer.
Hematol Oncol Clin North Am - 01-Apr-2005; 19(2): 219-35
L. Chronic Cough
1) Irwin RS, Madison JM, The persistently troublesome cough, Am J Respir Crit
Care Med 2002, 165(11): 1469-74.
2) Evidence-Based Clinical Practice Guidelines: ACCP Diagnosis and
Management of Cough Executive Summary, Chest 2006, 129:1S–23S
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
PULMONARY LOGSHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
ROTATION MONTH_____________
* Any lung biopsy during the month, irrespective of whether the patient is staff or not, must be personally
reviewed by resident under direct supervision of attending physician, (no minimum # requirement)
LABORATORY
DATA
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
Lung Biopsy*/ VQ
Scans
CXR and CT
scans
PFT
ABG
RESIDENT NAME:____________________________________________
LABORATORY
DATA
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
MR#
Interpretation of
result by resident
(diagnosis/
management plan)
Comment by
supervising attending
(correct/not, missed
findings etc)
SIGNATURE of
Supevising
attending & DATE
Sputum stain and
culture
CXR and CT
scans
PFT
ABG
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
PULMONARY OUTPATIENT ATTENDANCE SHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
DATE
ROTATION MONTH_____________
COMMENTS (IF ANY) BY ATTENDING
SIGNATURE OF
ATTENDING
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
VENTILATOR ROUND ATTENDANCE SHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
DATE
ROTATION MONTH_____________
COMMENTS (IF ANY) BY ATTENDING
SIGNATURE OF
ATTENDING