INTERNAL MEDICINE CLERKSHIP COURSEBOOK
I.
INTRODUCTION
The internal medicine clerkship is one of the essential clinical experiences for medical
students. In this clerkship, students are expected to begin developing many of the
basic competencies of doctoring. The third year clerkship is meant to compliment
the experiences in the fourth/fifth year clerkship.
Those problems and medical conditions in Internal Medicine that every physician
should be able to manage, regardless of chosen specialty, will be emphasized. We
will provide you with clinical and didactic experiences that should stimulate learning.
This curriculum detailed below specifies and prioritizes course objectives in terms of
the basic generalist competencies, the specific learning objectives (knowledge, skills,
and attitudes) pertinent to these competencies, and includes the clinical experiences
and evaluation methods.
The goal in Internal Medicine Clerkship course is to have you identify clinical
problems in your patients through the integration of information derived from the
history and physical examination. You will use knowledge of pathophysiology and
clinical epidemiology in order to develop a reasoned differential diagnosis. Finally,
you will plan a logical and practical diagnostic evaluation, using the principles of
evidence-based medicine.
Your resident, attending physician, and tutors have also been provided with this
booklet. The information included is to assist in setting expectations for these
courses, for you, and for the faculty. Each course is to be viewed as a successive
part of the educational continuum.
The ability to learn independently is an essential trait for every physician to have and
very important for your success in these clerkships. You will have opportunities to
evaluate and take care of patients, discuss cases with your RMOs and attending
physician (DPJP), present cases to both teachers and student colleagues at Case
Presentations, and participate in Tutorials addressing common clinical problems and
Referat. Each of these experiences should stimulate you to ask questions and to
seek answers using the medical literature where appropriate. In particular, the
student conferences will present opportunities for you to actively participate in
clinical problem solving. The degree to which all students are prepared to do so will
largely determine how successful the Internships in Medicine will be as educational
experiences for you and your colleagues.
OUTLINE
1. Course Committee
2. Sites
3. General Information
4. Core Curriculum
5. Grading/Evaluation
6. Portfolio
7. Course Objectives
8. Core Competencies Curriculum
9. General Competencies
10. Core Topics
COURSE COMMITTEE
The course committee coordinates activities on Internal Medicine in all of the clinical
sites. The committee is involved in evaluation of students with borderline grades
and resolution of disputed grades.
The committee consists of the Clerkship Director and the Hospital Coordinators from
each of the clinical sites.
Internal Medicine Clerkship Director:
Faculty Medicine of UPH
Site Directors:
Siloam Lippo Village-RSUS :
Siloam Kebon Jeruk :
RS. POLRI :
RSPAD :
RS. Marinir Cilandak :
GENERAL INFORMATION
Internal medicine Clerkship Course is a 10 weeks course.
Preceptor based clerkship. It is divided into 8 groups of primary preceptor
There are two type of preceptor: primary preceptor and division preceptor
Primary preceptor is the preceptor in charge of the whole course of internal
medicine course for the students that are appointed.
Task:
 Teach the students during the ward visit
 Evaluate student’s workbook and logbook
 Evaluate student’s medical record everyday
 Teach bedside teaching session
 Evaluate and assess the case report
 Evaluate and assess the case presentation session
 Evaluate and assess the mini CEX (formative assessment)
 Evaluate and assess the global assessment for the whole course
Division preceptor is the preceptor in charge of division rotation in internal
medicine clerkship course.
(Cardiovascular and Pulmonology / @2 weeks course)
Task:
 Teach the student about medical problem in its division
 Teach the student about clinical symptoms and establishing diagnosis
 Teach the student about medical care and management
 Coordinate with primary preceptor about scheduling the time.
Supervision: The site directors at each teaching site bear the primary responsibility
for the development and maintenance of a program to fulfill the learning objectives
of the Externships in Medicine. The coordinator is responsible for organizing the
tutorials and seminars and encouraging faculty members to take the expected
approach toward student involvement in seminars and tutorials. Since there are
differences in student responsibilities for Internal Medicine, directors will also
reinforce at the beginning of each period, with the attending physician (DPJP) and
RMOs, the objectives to be met by the students assigned to their ward team.
Each student is part of a medical team usually consisting of one or two RMOs,
assistants, and an attending physician (DPJP). Students attend morning work rounds
each day and participate in attending rounds as scheduled. Students also work 1
night per week for night duty as scheduled.
The attending physician (DPJP/preceptor) has the primary responsibility for
educating students assigned to the ward team.
The immediate day-to-day
supervisor for students is the assistant. All of the physician-teachers with whom the
student has contact are expected to serve as positive role models.
Conferences: Each site has developed student-specific seminars. Most topics are
common to all of the sites, but the presentation has been developed at the site.
These are mandatory conferences and students are expected to attend and
participate. Each site has a student specific schedule. Departmental conferences are
routinely held at each of the hospitals. These conferences include medical grand
rounds, morning report, clinicopathological conferences, RMOs conferences, and
subspecialty conferences.
Students are welcome at departmental conferences,
although, if student-specific conferences are scheduled at the same time you are
expected to attend those instead.
Textbooks: Students are expected to do some reading in a general medicine
textbook as relates to conference topics and to their patients.
General Concise Textbooks
1. Harrison’s Principles of Internal Medicine
2. Cecil ‘s Textbook of Internal Medicine
3. Buku Ajar Ilmu Penyakit Dalam, PAPDI
4. Internal Medicine Essentials for Clerkship Students, American College of
Physicians
Work-ups and Write-ups Medical Record: Students are expected to work-up
(complete medical records) a minimum of fifteen patients during the rotation.
Students, who, through no fault of their own, do not reach the required minimum,
will not be considered deficient. More cases may be assigned. Students should
attempt to complete their history and physical examinations within 60 minutes.
Cases will be presented to the attending physician during attending rounds. It is at
this time, or previously in review with the RMO or Assistant, that factual historical
items should be substantiated and physical findings corroborated.
Case Report:
Students are expected to write 4 case reports (1 every 2 weeks). Students write a
maximal 5 pages reports including the short discussion. Case report will be
presented orally to the preceptors.
SEMINARS (Clinical Science Session/CSS)
There are two form of required seminar: Case Presentation and Referat:
Case Presentation
One student is expected to make and present one case presentation. The selected
case chooses from the write up cases. Student complete a written material consist of
maximal 10 pages with detail of history and clinical finding, simple basic theory
related to the case and a constructive discussion. Student will presented in 15-20
minutes and discuss with preceptor and other students for another 20-30 minutes.
Referat/ Seminars:
One student is expected to make and present one referat. Referat is review of
disease consist of concise of epidemiology, risk factor, pathogenesis, clinical finding,
further examination, therapeutic approach and prognosis. There are core content
seminar consist of essential general internal medicine and medical emergency.
Referat consists maximal of 15 pages. Student presents the referat in 20 minutes,
and it follows with discussion for 30 minutes with preceptor and students.
Nine general topics have been selected for tutorials. This does not represent the
entirety of the information you are expected to know after completion of this
clerkship.
Bedside Teaching
Students and preceptor have a dedicated and protected 90 minutes (1.5 hour)
of Bedside teaching activities. Students should prepare them-self for the case
and let the preceptor knows which patient that is taken as bedside teaching patient.
Student should be able to take a comprehensive history, good physical examination,
established provisional diagnosis, and differential diagnosis, plan treatment and
educate patient and their family.
Valued Student Performance Behaviors: The course committee has had many
discussions about what makes an outstanding student. Medical knowledge, skills in
gathering and organizing data, and excellent judgment are all essential components.
Perhaps most important is attitude. Students who are self-starters, who create
opportunities for their own learning, who take obvious pleasure in the learning
opportunities on the ward are students who will stand out for us. Look at the
evaluation forms.
If you are always bringing in new information for the team, you will be highly
regarded. Accept constructive criticism as a help to your improvement (don’t be
defensive). If you don’t know, don’t make something up.
If you complain about reading and do it only grudgingly, if you complain about
learning value of patients admitted to you, these are red flags. Before you
complain, be sure you have something to complain about.
Feedback: Since ongoing feedback is fundamental to a successful educational
relationship, students should feel free to ask about their progress. Feedback from
faculty and residents to students is extremely important in providing the opportunity
to improve clinical performance. During the Externships in Medicine, students will
be expected to initiate meetings at mid-rotation, first with their supervising
resident (if assigned) and then with their attending physician, to discuss both
strengths and areas needing improvement. The content of this feedback is outlined
in the Evaluation forms for this course.
A similar process should occur at the end of the rotation so that the student, resident
and faculty can discuss the student’s progress relative to the mid-rotation
assessment and the Course Objectives. These student-initiated sessions should make
the feedback process more efficient, effective, and palatable for the faculty and
residents; and equally important, promote student self-assessment through analysis
of specific examples of their own performance.
Absence: Each student is assigned to a team and is expected to function as a
responsible member of that team. Any unexcused absence may result in a failing
grade. Absence for any reason but illness or emergency must be approved ahead of
time by the hospital coordinator. An opportunity to make up required work will be
provided when such absences are cumulatively less than one week in length.
Absence for more than two weeks for any reason will automatically result in the
student having to repeat the entire externship. Absences of one to two weeks will be
handled on an individual basis by the hospital coordinator and course director. Prior
approval from the hospital site coordinator is required.
If you, for some reason, miss the OSCE exam, the only option for taking this will be
to wait for the next administration 10 weeks later at the conclusion of the next
clerkship.
GRADING AND EVALUATION
Information from a variety of sources will be compiled in the evaluation and grading
of each student. The hospital coordinator at each site is responsible for compiling
the evaluations and using these evaluations along with the scores on the
examination(s) to assign the final grade. In the event of a disputed grade, failing
grade on any exam or any area of performance that was judged as “below
expectations”, the Course Committee will only assign a final grade after thorough
review of student performance.
Grades will be Exceed Requirement, Meet Requirement, Need Improvement
and Fail.
The targeted grade distribution will be 10% Outstanding, 75% Excellent and 10%
Satisfactory and Fail less than 5%.
Final Grade

30% of the grade will be based upon clinical activities as evaluated by
primary preceptor, division preceptor, attending, RMO, and nurses (global
assessment)

30% of the grade will be based on OSCE

15% of the grade will be based on medical record evaluation

15% of the grade will be based on case report

5% of the grade will be based on case presentation

5% of the grade will be based on referat
Failure
Failing grades can be assigned based on:
1) Professionalism,
2) Unsatisfactory Clinical Performance or
3) Failure of the written exam(s).
In the event a student fails the OSCE Exam, the student will be allowed to repeat the
exam without repeating the course (assuming clinical performance was acceptable).
A second failure will require remediation of the entire clerkship. If a student fails
both of the exams will be reviewed on an individual basis and the student may be
asked to remediate the entire clerkship.
If your performance is judged “below expectations” in any area on any final
evaluation, all your evaluations and any other pertinent information about your
performance will be carefully reviewed by the Medicine Clerkship Committee who will
then determine your grade. If you are assigned a grade of Fail you must follow the
procedures outlined by the Medical School.
If a student’s performance on the clerkship was passing but marginal, further review
of the students overall medical school performance may be recommended.
COURSE OBJECTIVES
General Overview
For Internal Medicine Clerkship the student will be able to:
 Elicit a record an appropriately complete, cogent, and organized medical
history.
 Conduct and record an appropriately complete and accurate physical
examination
 Communicate in a facilitative, effective, efficient, and educational manner
with patients and their families.
 Identify the social and psychological components of patients’ medical
problems.
 Use knowledge of the pathophysiology of signs and symptoms to establish
clinical correlation’s with disease processes.
 Develop an accurate and complete problem list.
 Formulate a reasoned differential diagnosis for each problem.
 Formulate an appropriate plan for confirming the diagnosis.
 Use knowledge of the indications and limitations of clinical sources such as
laboratory and imaging studies, consults, family input and old records to
request and interpret data pertinent to problem solving.
 Use information from textbooks, and journals to study general topics related
to patient’s problems.
 Observe, review, reassess, and revise clinical management daily, record
patient progress in the medical record, and make a verbal report to the health
care team.
 Communicate clearly and succinctly to colleagues and other members of the
health care team.
 Apply those technical skills commonly employed on a medical service.
 Formulate an appropriate initial treatment program taking into account the
urgency of the patient’s problems.
 Formulate an appropriate ongoing health care plan for patients within their
socio-economic situation.
 Assume independent responsibility for the primary care of patients with
appropriate supervision.
 Recognize and respond appropriately to common medical emergencies.
 Demonstrate independent learning in response to questions raised in the
clinical setting by using textbooks, journal articles, media, computer-based
tools and other resources.
 Demonstrate an expanded fund of knowledge by active participation in
tutorial sessions.
 Students are able fulfill the expectation and requirement of basic Indonesian
doctor competency in internal medicine field.
Technical and Interpretation Skills:
Students are expected to acquire certain technical skills and interpretation that
are commonly employed in medical care. Wherever possible and appropriate
students are encouraged to participate in procedures under adequate
supervision. The student should be able to:
 Record and interpret an ECG.
 Perform venipuncture for blood specimens or intravenous therapy.
 Perform and interpret a blood smear
 Test for the presence of blood (e.g. by hemoccult) in stool.
 Interpret cardiac enzymes.
 Interpret liver enzymes
 Interpret a complete blood count.
 Interpret results of a urine analysis.
 Interpret gram stain results of body fluids.
 Interpret bedside tests of pulmonary function.
 Interpret chest x-ray findings.
 Interpret arterial blood gas measurements.
 Interpret serum electrolyte measurements.
 Interpret results of body fluid analysis including joint, pleural, peritoneal,
spinal
Each objective follows a standard sequence of steps appropriate to effective design
of a clinical course: 1) specifying and prioritizing course objectives in behavioral
terms as the competencies to be mastered; 2) identifying the specific learning
objectives pertinent to each of these competencies and stating them in terms of
requisite knowledge, skills, and attitudes; 3) formulating clinical and classroom
experiences appropriate for the learning objectives; and 4) establishing evaluation
methods for measuring the desired competencies.
DETAILED GENERAL CLINICAL CORE COMPETENCIES
Learning objectives for each competency
 Diagnostic Decision-Making
 Case Presentation Skills
 History Taking and Physical Examination
 Communication and Relations with Patients and Colleagues
 Test Interpretation
 Therapeutic Decision Making
 Bioethics of Care
 Self Directed Learning
 Prevention
 Coordination of Care
 Basic Procedures
 Geriatric Care
 Community Health Care
 Nutrition
 Advanced Procedures
 Continuous Improvement in Systems of Medical Practice
DIAGNOSTIC DECISION-MAKING
Rationale
Physicians are responsible for directing and conducting the diagnostic evaluation of a
broad range of patients, including acutely and chronically ill patients. In a time of
rapidly proliferating tests, internists must design safe, expeditious, and cost-effective
diagnostic evaluations. This requires well-developed diagnostic decision-making skills
that incorporate probability-based thinking.
Specific Learning Objectives
A. Knowledge: Each student should be able to describe:
1. key history and physical examination findings pertinent to the differential
diagnosis.
2. information resources for determining diagnostic options for patients with
common and uncommon medical problems.
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.
4. the relative cost of diagnostic tests.
5. how critical pathways or practice guidelines can be used to guide diagnostic
test ordering.
6. the method of deductive reasoning.
B. Skills: Each student should be able to:
1. formulate a differential diagnosis based on the findings from the history and
physical examination.
2. use probability-based thinking to identify the most likely diagnoses.
3. use the differential diagnosis to help guide diagnostic test ordering and
sequence.
4. use 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.
5. participate in selecting the diagnostic studies with the greatest likelihood of
providing useful results at a reasonable cost.
C. Attitudes: Each student should:
1. incorporate the patient’s perspective into diagnostic decision-making.
2. limit the chances of false positive/false negative results by demonstrating
thoughtful test selection.
3.
CASE PRESENTATION SKILLS
Rationale
Communicating patient care information to colleagues and other health 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 presentation: written and oral,
new patient and follow-up, inpatient and outpatient.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. components of comprehensive and abbreviated case presentations (oral
and written) and the settings appropriate for each.
B.
Skills: Each student should be able to:
1. prepare legible, comprehensive, and focused new patient workups that
include the following features as clinically appropriate:
 present illness organized chronologically, without repetition,
omission, or extraneous information.
 a comprehensive physical examination with detail pertinent to
the patient’s problem.
 a succinct and, where appropriate, unified list of all problems
identified in the history and physical examination.
 a differential diagnosis for each problem (appropriate to level of
training).
 a diagnosis/treatment plan for each problem (appropriate to
level of training).
2. orally present a new patient’s case in a logical manner, chronologically
developing the present illness, summarizing the pertinent positive and
negative findings as well as the differential diagnosis and plans for further
testing and treatment.
3. orally present a follow-up patient’s case, in a focused, problem-based
manner that includes pertinent new findings and diagnostic and treatment
plans
4. select the appropriate mode of presentation that is pertinent to the clinical
situation.
C.
Attitudes: Each student should:
1. demonstrate a commitment to improving case presentation skills by
regularly seeking feedback on presentations.
2. accurately and objectively record and present data.
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 exam with a wide variety of patients, including healthy adults
(both young and old), adults with acute and chronic medical problems, and adults
with complex life-threatening diseases. 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 well developed history-taking and physicaldiagnosis 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 general internal
medicine.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
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.
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.
3. The pathophysiologic mechanisms that explain key findings in the history
and physical exam.
4. The diagnostic value of history and physical exam information.
B.
Skills: Each student should be able to:
1. Use language appropriate for each patient.
2. Use non-verbal techniques to facilitate communication and pursue
relevant inquiry.
3. Elicit the patient’s chief complaint as well as a complete list of the
patient’s concerns.
4. Obtain a patient’s history in a logical, organized, and thorough manner,
covering the history of present illness; past medical history (including
usual source of and access to health care, childhood and adult illnesses,
injuries, surgical procedures, obstetrical history, psychiatric problems,
hospitalizations, transfusions, medications, tobacco and alcohol use, and
drug allergies); preventive health measures; social, family, and
occupational history; and review of systems.
5. Obtain, whenever necessary, supplemental historical information from
other sources, such as significant others or previous physicians.
6. Demonstrate proper hygienic practices whenever examining a patient.
7. Position the patient and self properly for each part of the physical
examination.
8. Perform a physical examination for a patient in a logical, organized,
respectful, and thorough manner, giving attention to the patient’s general
appearance, vital signs, and pertinent body regions.
9. Adapt the scope and focus of the history and physical exam appropriately
to the medical situation and the time available.
C.
Attitudes: Each student should:
1. Recognize the essential contribution of a pertinent history and physical
examination to the patient’s care by continuously working to improve
these skills.
2. Establish a habit of updating historical information and repeating
important parts of the physical exam during follow-up visits.
3. Demonstrate consideration for the patient’s feelings, limitations, and
cultural and social background whenever taking a history and performing
a physical exam.
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 sensitivity and flexibility. The
result of proficiency in communication and interpersonal skills is increased
satisfaction for both doctor and patient.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
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.
2. The role and contribution of each team member to the care of the patient.
3. The role of psychosocial factors in team interactions.
4. The role of the physician as patient advocate.
B.
Skills: Each student should be able to:
1. Demonstrate appropriate listening skills, including verbal and non-verbal
techniques (e.g., restating, probing, clarifying, silence, eye contact,
posture, touch) to demonstrate empathy and help educate the patient.
2. Demonstrate effective verbal skills including appropriate use of open- and
closed-ended questions, repetition, facilitation, explanation, and
interpretation.
3. Determine the information that a patient has independently obtained
about his/her problems.
4. Identify patient’s emotional needs (patient’s FIFE)
5. Seek the patient’s point of view and concerns about his/her illness and the
medical care he/she is receiving.
6. Determine the extent to which a patient wants to be involved in making
decisions about his/her care.
7. Assess patient commitment and adherence to a treatment plan taking into
account personal and economic circumstances.
8. Work with a variety of patients, including multiproblem patients, angry
patients, somatizing patients, and substance abuse patients.
9. Work as an effective member of the patient care team, incorporating skills
in interprofessional collaboration.
11. Give and receive constructive feedback.
C.
Attitudes: Each student should:
1. Work hard to develop effective doctor-patient communication skills.
2. Take into consideration in each case the patient’s psychosocial status.
3. Demonstrate respect for patients.
4. Demonstrate actively involving the patient in his/her health care whenever
possible.
5. 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.
6. Respond pertinently to patient concerns.
7. Attend to or advocate for the patient’s interests and needs in a manner
appropriate to the student’s role.
TEST INTERPRETATION
Rationale
Physicians, in particular general internists, order a wide variety of medical tests in
the course of their clinical practice. They must be able to interpret the results of such
tests accurately and properly determine how the results should influence patient
management.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. The various components of a complete blood count, blood smear,
electrolyte panel, general chemistry panel, electrocardiogram, urinalysis,
pulmonary function tests, and body fluid cell counts and chemistries.
2. Range of normal variation in the results of a complete blood count, blood
smear, electrolyte panel, general chemistry panel, electrocardiogram,
chest x-ray, urinalysis, pulmonary function tests, and body fluid cell
counts and chemistries.
3. Results of the above tests in terms of the related pathophysiology.
4. Test sensitivity, test specificity, pre-test probability, and predictive value.
5. How errors in test interpretation can affect clinical outcomes and costs.
B.
Skills: Each student should be able to:
1. Interpret a blood smear, gram stain, electrocardiogram, chest X-ray, and
urinalysis.
2. Record the results of laboratory tests in an organized manner, using flow
sheets when appropriate.
3. Estimate post-test probability based on test results and state the clinical
significance of these findings.
C.
Attitudes: Each student should:
1. Demonstrate estimating the implications of test results before ordering
tests and after test results are available.
2. Personally review X-ray films, blood smears, etc., to assess the accuracy
and significance of the results.
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.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Information resources for determining medical and surgical treatment
options for patients with common and uncommon medical problems.
2. Key factors to consider in choosing among treatment options, including
risk, cost, evidence about efficacy, and consistency with pathophysiologic
reasoning.
3. How to use critical pathways and clinical practice guidelines to help guide
therapeutic decision making.
4. Factors that frequently alter the effects of medications, including drug
interactions and compliance problems.
5. Factors to consider in selecting a medication from within a class of
medication.
6. Factors to consider in monitoring a patient’s response to treatment,
including potential adverse effects.
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.
8. Methods of monitoring therapy and how to communicate them in both
written and oral form.
B.
Skills: Each student should be able to:
1. Formulate an initial therapeutic plan.
2. Access and utilize, when appropriate, information resources to help
develop an appropriate and timely therapeutic plan.
3. Explain the extent to which the therapeutic plan is based on
pathophysiologic reasoning and scientific evidence of effectiveness.
4. Begin to estimate the probability that a therapeutic plan will produce the
desired outcome.
5. Write prescriptions accurately.
6. Counsel patients about how to take their medications and what to expect
when they take their medications, including beneficial outcomes and
potential adverse effects.
7. Monitor response to therapy.
C.
Attitudes: Each student should:
1. Incorporate the patient in therapeutic decision-making, explaining the
risks and benefits of treatment.
2. Respect patient’s informed choices, including the right to refuse
treatment.
3. Incorporate the elements of patient autonomy, treatment efficacy, quality
of life, and societal demands into decision-making.
4. Provide close follow-up of patients under care.
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 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.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Basic elements of informed consent.
2. Circumstances under which informed consent is necessary and
unnecessary.
3. Basic concepts of autonomy, treatment efficacy, quality of life, and
societal demands.
4. Potential conflicts between individual patient preferences and societal
demands.
5. The role of the physician in making decisions about the use of expensive
or controversial tests and treatments.
B.
Skills: Each student should be able to:
1. Participate in a discussion about advance directives with a patient.
2. Participate in informed consent for a procedure.
3. Participate in the care of a consent-requiring terminally ill patient.
4. Participate in a preceptor’s discussion with a patient about a requested
treatment that may not be considered appropriate (e.g., notcosteffective).
C.
Attitudes: Each student should:
1. Take into account the individual patient’s perspective and perceptions
regarding health and illness.
2. Demonstrate a commitment to caring for all patients, regardless of
gender, race, socioeconomic status, intellect, sexual orientation, ability to
pay, or cultural background.
3. 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.
4. Recognize the potential conflicts between patient expectations and
medically appropriate care.
PRACTICE BASED LEARNING AND IMPROVEMENT
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.
Prerequisites
Basic library skills, including the ability to perform an electronic literature search.
Critical appraisal skills and evidence based medicine.
Understanding of basic concepts of biostatistics and clinical epidemiology.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Key sources for obtaining updated information on issues relevant to the medical
management of adult patients.
2. A system for managing information from a variety of sources.
3. Key questions to ask when critically appraising articles on diagnostic tests or
therapies.
B.
Skills: Each student should be able to:
1. Perform a computerized literature search to find articles pertinent to a clinical
question.
2. Demonstrate critical review skills.
3. Read critically about issues pertinent to their patients.
4. Assess the limits of medical knowledge in relation to patient problems.
5. Use information from consultants critically.
6. Recognize when he or she needs additional information to care for the patient.
7. Ask colleagues (students, residents, nurses, faculty) for help when needed.
8. Make use of available instruments to assess one’s own knowledge base.
C.
Attitudes: Each student should be able to:
1. Demonstrate self-directed learning in every case.
2. Acknowledge gaps in knowledge to both colleagues and patients and request
help.
COORDINATION OF CARE
Rationale
The task of coordinating a patient’s care is central to the general internist’s role and
involves communication with the patient and his/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.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. The role of consultants and their limits in the care of a patient.
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.
3. The role of the primary care physician in coordinating the comprehensive
and longitudinal patient care plan, including communicating with the
patient and family through telecommunications and evaluating patient
well-being through home health and other care providers.
4. The role of the primary care physician in the coordination of care during
key transitions (e.g., outpatient to inpatient, inpatient to hospice, etc.).
B.
Skills: Each student should be able to:
1. Discuss with the patient (and family as appropriate) ongoing health care
needs, using appropriate language, avoiding jargon and medical
terminology.
2. Participate in requesting a consultation and identifying the specific
question(s) to be addressed.
3. Participate in the discussion of the consultant’s recommendations.
4. Participate in developing a coordinated, ongoing care plan in the
community.
5. Obtain 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.
C.
Attitudes: Each student should:
1. Demonstrate teamwork and respect toward all members of the health care
team.
2. Demonstrate responsibility for patients’ overall welfare.
3. Participate, whenever possible, in coordination of care and in provision of
continuity.
GERIATRIC CARE
Rationale
Care of the elderly is one of the traditional functions of the general internist, and
with the “greying” of the population; geriatrics will become a larger part of the
practice of all physicians who care for adults. The student should understand the
unique health care needs and presentation of the elderly, key management
strategies, and the importance of an interdisciplinary approach to care.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Functional implications of aging organ systems.
2. Special nutritional needs of the elderly.
3. Key illnesses in the elderly, focusing on their often atypical presentation
(e.g., urinary tract infection, pneumonia, tuberculosis, depression, thyroid
disease, myocardial infarction, acute abdomen).
4. Identify the major geriatric problems (geriatric giants)
B.
Skills: Each student should be able to:
1. Take a history from a geriatric patient with special emphasis on physical
and mental functioning.
2. Perform a physical examination and functional assessment on an elderly
patient, adapting it to possible conditions of frailty, immobility, hearing
loss, memory loss, and other impairments.
3. Perform a mental status examination to evaluate confusion and/or
memory loss in an elderly patient.
4. Identify patients at high risk for falling.
5. Practice an interdisciplinary approach to management and rehabilitation of
elderly patients.
C.
Attitudes: Each student should:
1. Always obtain historical information from significant others, whenever
possible.
2. Respect the increased risk for iatrogenic complications among elderly
patients by always taking into account risks and monitoring closely for
complications.
3. Demonstrate respect to older patients by making efforts to preserve their
dignity.
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, should assess nutritional factors on a routine basis. Physicians, particularly
general internists, also should be prepared to provide patients with basic advice
regarding ways to optimize their nutritional status. All physicians also need to have
at least a basic working knowledge of the principles of nutritional assessment and
intervention.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Key symptoms and signs that may indicate a nutritional problem.
2. Nutritional problems that occur most commonly in adults.
3. Common medical problems that can cause nutritional deficiencies.
4. Contributions of dietary indiscretion to hyperlipidemia, diabetes,
hypertension, etc.
B.
Skills: Each student should be able to:
1. Obtain a nutritional history for patients with obesity, hyperlipidemia,
diabetes mellitus, hypertension, alcoholism, cancer, COPD, CHF, and GI
diseases, giving attention to weight change, appetite, eating habits,
digestive problems, dental problems, physical handicaps, psychiatric
problems, socioeconomic factors, alcohol use, medications, and physical
activity.
2. Identify physical findings relevant to the nutritional assessment of patients
including: truncal distribution, abdominal striae, cachexia, decubitus
ulcers, temporal wasting, glossitis, peripheral neuropathy, peripheral
edema, ascites, depression, and weakness.
3. Order appropriate initial tests for evaluating a patient’s nutritional status.
C.
Attitudes: Each student should:
1. Assess the nutritional status of each patient.
2. Consult a dietitian for patients with significant nutritional problems.
BASIC PROCEDURES
Rationale
For many students, the internal medicine clerkship is where the basic procedural
skills required in other clerkships, sub internships, and residencies are learned.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Key indications, contraindications, risks, and benefits of each of the
following basic procedures:
 Venipuncture.
 Blood culture.
 Arterial blood gas.
 Electrocardiogram.
 Nasogastric tube.
 Urethral catheterization.
 Peripheral intravenous catheter insertion.
 Throat culture.
 Digital rectal examination.
 Place and interpret a tuberculin skin test (PPD).
2. Alternatives to a given procedure.
3. What the patient’s experience of the procedure will be.
B.
Skills: Each student should be able to:
1. Demonstrate 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.
2. Demonstrate step-by-step performance of basic procedures with technical
proficiency.
3. Observe precautions and contraindications for the procedures used.
C.
Attitudes: Each student should:
1. Always participate in obtaining informed consent for basic procedures they
perform or in which they participate.
2. Explain what the patient’s experience is likely to be in understandable
terms.
3. Communicate risks and benefits to patients.
4. Always make efforts to maximize patient comfort during a procedure.
ADVANCED PROCEDURES
Rationale
A number of advanced procedures may be performed by general internists but
usually not third-year clerks. However, a 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.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. Key indications, contraindications, risks, and benefits of each of the
following advanced procedures:
 Arthrocentesis.
 Central venous catheterization.
 Flexible sigmoidoscopy.
 Lumbar puncture.
 Thoracentesis.
 Paracentesis.
 Swan Ganz catheterization.
 Bone marrow aspiration.
 Skin biopsy.
2. Alternatives to a given procedure.
3. What the patient’s experience of the procedure will be.
B.
Skills: Each student should be able to:
1. Participate 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.
C.
Attitudes: Each student should:
1. Demonstrate responsibility for helping to provide informed consent.
2. Demonstrate a commitment to explaining the patient’s experience in
understandable terms.
3. Communicate risks and benefits of procedures to patients regularly.
4. Maximize patient comfort during a procedure.
CONTINUOUS IMPROVEMENT IN SYSTEMS OF MEDICAL PRACTICE
Rationale
Clinical education has emphasized the role of the physician as an individual decision
maker. Problems with cost and quality of care have usually been attributed to errors
in individual decision-making. In recent years, it has become clear that systems,
from simple to complex, are also critical in achieving high quality patient care.
Furthermore, we have begun to think of quality from the patient’s perspective as well
as that of the profession. The physician, both as an individual and as a member of
the health care community, must make use of systems thinking and participate in
the process of assessing current practice and testing new methods to improve
patient care.
Specific Learning Objectives
A.
Knowledge: Each student should be able to describe:
1. 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.
2. The analysis and improvement of systems to address common quality
problems (treatment delays, medication errors, failure to give preventive
care).
3. Principles of medical record organization in both inpatient and ambulatory
settings.
4. The need for a multidimensional approach to the assessment of quality,
including the patient’s perspective of quality.
5. The relationship of quality and cost in health care.
B.
Skills: Each student should be able to:
1. Use hospital-based support systems to assist in making clinical decisions
(e.g., antibiotic control program).
2. Recognize systems flaws in the provision of care at the clerkship site (e.g.,
inability to arrange a post-discharge appointment within a needed time
frame, delays in obtaining test results).
3. Use patient education materials (e.g., pamphlets for patients started on
warfarin), which help patients, participate in their care.
4. Use the medical records system efficiently and write legible notes.
5. Work collaboratively with other health professionals in the delivery of
care.
C.
Attitudes: Each student should:
1. Recognize the importance of systems—especially interprofessional
collaboration—in delivering high quality patient care.
2. Strive to improve the timeliness of their diagnostic and therapeutic
decision making to improve quality of care, increase patient satisfaction,
and reduce cost.
Core Content Seminars
1.
Anemia
Students should be able to define and describe:
a.
Classification and morphologic definition of anemia as normocytic,
microcytic, or macrocytic.
b. Morphological and laboratory characteristics of iron deficiency
anemia, megalobalistic anemia, hemolytic anemia including
microangiopathic, and congenital disorder (sickle cell, thalessemias).
c.
Indications, contraindications, and complications of blood transfusion.
2. Hypertension
Students should be able to define and describe:
a.
Classification and prevalence of primary and secondary hypertension
and the most common causes of secondary hypertension.
b. Hypertensive urgency and emergency and their initial management.
c.
Pathophysiology, presentation, and diagnostic approach for Cushing’s
disease, renovascular hypertension, pheochromocytoma, and
hyperaldosteronism.
d. Manifestations of target-organ damage from hypertension.
2.
Jaundice
Students should be able to:
a.
Outline a differential diagnosis for yellow skin, including important
features from the history, physical examination, and laboratory data.
b. Outline a differential diagnosis for jaundice (differentiating
obstructive from non-obstructive) and identify distinguishing clinical
features from the history, physical examination, and laboratory data
of each major etiology.
c.
Outline diagnostic and management strategies for:
(1) Obstructive jaundice
(2) Non-obstructive jaundice
3.
Dyspnea
Students should be able to:
a.
Discuss the differential diagnosis of a patient presenting with
(1) Acute dyspnea
(2) Chronic dyspnea
b. Discuss the signs, symptoms, and initial evaluation of:
(1) Left ventricular failure *
(2) Right ventricular failure
(3) Pulmonary embolism
(4) Asthma/COPD exacerbation
(5) Interstitial lung disease
c.
Discuss the diagnostic and therapeutic management of the case
presented.
4.
Venous Thromboembolism
Students should be able to:
a.
Discuss risk factors for developing thrombophlebitis
b. Discuss presenting symptoms of thrombophlebitis and pulmonary
embolus/infarction
c.
Discuss the long term sequelae of DVT
5.
Fever
Students should be able to:
a.
Describe normal characteristics of thermal regulation, such as diurnal
variations in temperature.
b. Describe methods of obtaining temperatures and their limitations.
c.
Describe the significance of accompaniments of fever, such as chills,
seizures, tachycardia.
d. List seven general disease categories, which are often accompanied
by fever.
e.
Outline the differential diagnosis for fever in a hospitalized patient, in
an immunocompromised patient, in a patient with a fever and
pulmonary infiltrates (pneumonia*).
f.
Describe the therapeutic management of fever for patients, defined
in e above, including the indications for antibiotics or other specific
therapy.
g. Define fever of unknown origin and plan, in general terms, the
evaluation of a patient with this disorder.
6.
Chest pain
Students should be able to describe and define:
a.
Signs and symptoms associated with ischemic cardiac pain (stable
and unstable angina), non-ischemic cardiovascular pain (dissecting
aortic aneurysm, acute pericardial pain), valvular heart disease
(aortic stenosis and mitral valve prolapse), GI disorder
(gastroesophageal reflux and esophageal spasm), pulmonary
disorders (pneumothorax, pulmonary embolism, inflammation of the
pleura), and musculoskeletal disorders (costochondritis and muscular
strain).
b. Factors that exacerbate angina pectoris.
c.
Cardiac risk factors.
7.
Gastrointestinal Hemorrhage
Students should be able to:
a.
Outline and describe clinical features that distinguish upper from
lower gastrointestinal bleeding.
b. Describe how to determine the magnitude of blood loss.
c.
Describe the approach for hemodynamic resuscitation of clinically
important blood loss, including indications for transfusion of blood
products.
d. Outline a differential diagnosis for:
(1) Upper gastrointestinal bleeding
(2) Lower gastrointestinal bleeding
e.
Describe the indications for and utility of various investigative
procedures for delineating the source of bleeding (e.g., endoscopy,
angiography, barium studies).
8.
Diabetes
Students should be able to describe and define:
a.
b.
Diagnostic criteria for, and pathogenesis, genetics, epidemiology,
major causes of morbidity and mortality, and presenting sign and
symptoms of type I and type II diabetes mellitus.
Signs and symptoms of diabetic ketoacidosis and nonketotic
hyperglycemic coma.
Management of Medical Emergencies (1 seminar per week).
These seminars focus on the recognition and management of common medical
emergencies. Students are expected to be prepared to participate actively in the
discussions.
Topics which will be covered include:
1. Shock Students should be able to:
a. Describe the hemodynamic and metabolic events that occur in the
shock state
b. Describe the clinical findings of shock.
c. Discuss the major categories of shock (e.g., hypovolemia, cardiogenic,
sepsis) and the clinical differentiation of these states.
d. Discuss the differential diagnoses of each of the major categories of
shock.
e. Discuss the clinical management of each type of shock state. Discuss
the role of hemodynamic monitoring in the management of shock.
2. Acute Respiratory Failure Students should be able to:
a. Define respiratory failure.
b. Discuss the clinical signs of respiratory failure.
c. Give three examples of patient diagnoses, which may present with
respiratory failure.
d. Differentiate cardiogenic pulmonary edema from adult respiratory
distress syndrome (ARDS), with respect to pathophysiology.
e. Discuss the pathophysiology of hypoxemia in asthma vs. ARDS;
include reasons for differences in treatment of hypoxemia in each
case.
f. Describe how to determine when the patient requires mechanical
ventilation for each of the following etiologies:
(1) COPD exacerbation
(2) Asthma
(3)ARDS
(3) Bellows failure (e.g., Guillian-Barre, ALS)
g. Discuss the complications of mechanical ventilation and of PEEP.
h. Discuss the therapeutic management of acute respiratory failure of the
case presented.
3. Electrolyte Disorders Students should be able to describe and define:
a. The pathophysiology, presenting signs and symptoms, differential
diagnosis (most common causes), and an approach to a patient with:
elevated or decreased blood volume, elevated or decreased serum
sodium, potassium, calcium, phosphorous, magnesium; simple acidbased disorders.
b. How to calculate total body water and understand its distribution.
c. How to determine the etiology hyponatremia and hypernatremia.
d. The risks of too rapid or delayed therapy for hyponatremia.
e. How to calculate the anion gap and explain its relevance to
determining the cause of a metabolic acidosis.
f.
The types of fluid preparations and methods of administration to treat
fluid and electrolyte disorders.
g. Causes and treatment of hyperkalemia.
4. Acute Kidney Injury Student should be able to describe and define:
a. Acute Kidney Injury (AKI) as a rapid decline in glomerular filtration
rate (GFR) and retention of nitrogenous waste products and discuss
and distinguish between the three major pathophysiologic etiologies
for ARF:
(1) decreased renal perfusion (pre-renal)
(2) intrinsic renal disease (renal)
(3) acute renal obstruction (post-renal)
b. Define AKI with Risk, Injury and Failure according to urine output and
creatinine serum.
c. The difference between and the major pathophysiologic etiologies of
“pre-renal” ARF including:
(1) hypovolemia
(2) decreased cardiac output
(3)systemic vasodilatation
(4)renal vasoconstriction
d. The difference between and the major pathophysiologic and etiologies
of intrinsic “renal” ARF including:
(1) vascular lesions
(2)glomerular lesions
(3)acute tubular necrosis (ATN)
(4)interstitial nephritis
(5)intra-tubule deposition/obstruction
e. The difference between the two major etiologies of ATN – ischemic and
nephrotoxic. Discuss the common offending agents involved with
nephrotoxic induced ATN.
f. The natural history, initial and supportive treatment modalities and
complications of acute renal failure.
5. Acute MI Student should be able to:
a. Recognize electrocardiographic changes indicative of myocardial
ischemia and infarction.
b. Interpret cardiac enzymes.
c. Describe a typical patient presentation for Acute MI.
d. Describe the major complications of Acute MI and how to recognize
and treat them.
e. Describe major therapeutic management options and their risks and
benefits.
THE CORE TOPICS
A content-based curriculum
A review of the core competencies underscores the fact that internal medicine is a
very broad, content-driven field that places a premium on cognitive work and
interpersonal skills. Some argue that any patient will suffice to teach internal
medicine’s basic approach to clinical problem solving, but most faculty agree that
mastery of a substantial fund of knowledge and the ability to function effectively
across a wide spectrum of problems are important hallmarks of the general internist
and should be emphasized in the core clerkship.
Consequently, this curricular model specifies a set of high-priority “training
problems” that help to define the core knowledge base, encourage mastery of basic
skills, and advance the attitudinal agenda. Utilizing both the inpatient and outpatient
services (Primary Care Clerkship) for clinical experiences (see the section
“Learning Experiences”) and limiting the training problem list to common clinical
conditions helps to ease the burden of case selection.
The training problems listed below and detailed in the following pages were those
receiving the highest scores from internal medicine faculty in a national survey of
Clerkship Directors. Each is presented with a statement regarding its rationale and
associated learning objectives (knowledge, skills, and attitudes).
LEARNING OBJECTIVES FOR EACH TRAINING PROBLEM
1. Abdominal Pain
2. Acute Fever (Dengue, Typhoid, Leptospirosis)
3. Altered Mental Status
4. Anemia
5. Asthma
6. Back Pain
7. Chest Pain
8. Cough
9. COPD
10. Diabetes Melitus
11. Dysuria
12. Fluid, Electrolyte, and Acid-Base Disorders
13. Joint Pain
14. Patients with a Known Disease Condition
15. Congestive Heart Failure
16. Dyslipidemia
17. HIV Infection
18. Hypertension
19. Pneumonia
20. Smoking Cessation
21. Substance Abuse
22. Common Cancers
23. Acute Kidney Injury
(On progress Modul)
24. Nephrotic Syndrome
25. Chronic Kidney Disease
26. Dyspepsia
27. Thyroid disorder
28. Tuberculosis
29. Hepatitis
30. Cirrhosis
31. Upper GI Bleeding
TRAINING PROBLEM: ABDOMINAL PAIN
Rationale
Abdominal pain is a common problem that can be caused by a wide variety of acute
and chronic disease processes, many of which can be life threatening. Mastery of the
approach to patients with abdominal pain is important to general internists because
they often are the first physicians to see such patients.
Specific Learning Objectives
A.
Knowledge: Students should be able to:
1. Describe and define principal types of pathophysiologic mechanisms of abdominal
pain (i.e., obstruction, peritoneal irritation, vascular insufficiency, abnormal
motility, mucosal irritation, metabolic aberrations, nerve injury, referred pain,
psychopathology)
2. Describe the relative likelihood of common causes of abdominal pain according to
the quadrant in which the pain is located
3. List symptoms and signs indicative of an acute abdomen
4. Describe the key diagnostic criteria for common causes of abdominal pain, based
on a history, physical exam and laboratory testing
5. Identify the indications and the limitations of the following principal diagnostic
studies necessary to differentiate among common causes of abdominal pain,
including:
fecal leukocytes
stool culture
stool guaiac
stool fat
hepatitis serology
liver enzymes
amylase and lipase
paracentesis
upper endoscopy
sigmoidoscopy
colonoscopy
barium studies
abdominal ultrasound
CT scan
radionuclide scan of hepatobiliary system
6. Identify indications for dietary intervention, drug therapy and therapeutic
procedures in patients with common causes of abdominal pain, and describe the
physiological basis and/or scientific evidence supporting each type of intervention
7. Identify indications for empiric therapy in patients with abdominal pain
8. Describe steps in a critical pathway for patients with an acute abdomen
B.
Skills: Students should demonstrate specific skills including:
1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among etiologies
of disease, including: elicit features of a patient’s abdominal pain, including
location, radiation, duration, associated symptoms, weight change, exacerbating
and remitting factors, surgery, medications, and family history.
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:
Demonstrate correct order and technique for examining the abdomen.
Perform an adequate rectal and pelvic exam (under supervision).
Identify relevant scars, abnormal bowel sounds and signs of peritoneal inflammation.
3. Differential diagnosis: students should be able to generate a list of the most
important and likely causes of a patient’s abdominal pain, recognizing specific
history and physical exam findings that distinguish between:
Peptic ulcer disease
Dyspepsia
Gastroparesis
Pancreatitis
Irritable bowel syndrome
Diverticulitis
Pseudomembranous colitis
Acute and chronic hepatitis
Inflammatory bowel disease
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 studies necessary to
determine the cause of a patient’s abdominal pain
5. Communication skills: Students should be able to:
Explain the results of the evaluation to the patient, taking into consideration the
patient’s knowledge about his/her condition
6. Basic and advanced procedure skills: Students should be able to:
Insert a nasogastric tube after explaining the procedure to the patient
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
selecting an appropriate medical regimen for patients with peptic ulcer disease,
dyspepsia, gastroparesis, pancreatitis, irritable bowel syndrome, diverticulitis, and
pseudomembranous colitis
determining when to prescribe medical therapy for patients with chronic hepatitis
determining when to involve a surgeon in the management of patients with peptic
ulcer disease, inflammatory bowel disease, cholecystitis, and pancreatitis
recognizing the value of psychotherapy in the management of chronic abdominal
pain
accessing and utilize appropriate information systems and resources to help
delineate issues related to abdominal pain
C.
Attitudes and Professional Behaviors: Students should be able to:
1. recognize the importance of involving a surgeon as soon as possible when a
patient is identified as having an acute abdomen
2. recognize the importance of patient preferences when selecting among treatment
options
TRAINING PROBLEM: ALTERED MENTAL STATUS
Rationale
The diagnosis and management of altered mental status requires a 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 these patients.
Specific Learning Objectives
A.
Knowledge: Students should be able to describe and define:
1. The pathophysiology, signs, and symptoms of the most common and most
serious causes of altered mental status including:
metabolic causes (i.e., hyper/hyponatremia, hyper/hypoglycemia,
hypercalcemia,
hyper/hypothyroidism,
hypoxia/hypercapnea,
hepaticencephalopathy,
uremic
encephalopathy,
drug
intoxication/withdrawal, Wernicke encephalopathy)
structural lesions (primary or metastatic tumor, intracranial hemorrhage,
infection)
cerebrovascular accident
transient ischemic attack
meningitis
encephalitis
seizures
postictal state
hypertensive encephalopathy
vasculitis
arrhythmias
heart failure
endocarditis.
2. The differential diagnosis of altered mental status based on historical and
physical findings, specifically being able to distinguish delirium from dementia
3. The key diagnostic criteria of altered mental status
4. The essential diagnostic tests to differentiate among possible causes of
altered mental status with their indications and contraindications including:
lumbar puncture
CT scan
MRI scan
EEG
drug screen
CBC with differential
electrolytes
serum chemzyme screen (glucose, renal/hepatic function tests)
VDRL
arterial blood gas
vitamin B12 and thiamine
thyroid function tests
5. Principles of management of common causes of altered mental status
6. Describe steps in a critical pathway for altered mental status
B.
Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including eliciting appropriate information from patients
with altered mental status, and/or their families, including the onset,
progression, associated symptoms, potential causes (including medications),
and level of physical and mental disability
2. physical exam skills: Students should be able to perform a physical exam
to establish the diagnosis and severity of disease including: neurologic exam
and construct a differential diagnosis based on historical and physical findings
3. differential diagnosis: Students should be able to generate a differential list
of the most important and most likely causes of a patient’s altered mental
status, recognizing specific history and physical exam findings that confirm or
refute a diagnosis of:
 metabolic causes:
 hyper/hyponatremia
 hyper/hypoglycemia
 hypercalcemia
 hyper/hypothyroidism
 hypoxia/hyperpnea
 hepatic encephalopathy
 uremic encephalopathy
 drug intoxication/withdrawal
 Wernicke encephalopathy
 structural lesions:
 primary or metastatic tumor
 intracranial hemorrhage
 infection
 cerebrovascular accident
 transient ischemic attack
 meningitis
 encephalitis
 seizures
 postictal state
 hypertensive encephalopathy
 vasculitis
 arrhythmias
 heart failure
 endocarditis
3. laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory and be able to interpret them, both prior to
and after initiation 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:
 lumbar puncture (color, opening pressure, glucose, protein, cell counts,
cytology, Gram’s and India ink stains, cultures, cryptococcal
 antigen, VDRL)
 CT scan and MRI scan
 EEG






drug screen
electrolytes
serum chemistries
arterial blood gas
vitamin B12 and thiamine
thyroid function tests
4. communication skills: Students should be able to: explain the results of the
evaluation to the patient, taking into consideration the patient’s knowledge
and ability to comprehend new information
5. basic and advanced procedure skills: Students should be able to:
 perform a venipuncture for collection of blood specimens
 insert a peripheral venous catheter
 obtain an arterial blood gas
 assist in performing a lumbar puncture after explaining the procedure to
the patient
6. management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients with altered metal status
including:
 writing appropriate fluid orders for the treatment of hyper/hyponatremia,
hyper/hypoglycemia, and hypercalcemia
 writing appropriate insulin and glucose orders for the treatment of
hyper/hypoglycemia
 writing appropriate antibiotic orders for the treatment of meningitis,
encephalitis, and endocarditis
 determining when to involve a neurosurgeon or neurologist in the
management of patients with altered mental status
 eliciting questions from the patient and/or family regarding the
management plan
 accessing and utilizing appropriate information systems and resources to
help delineate issues related to altered mental status.
C.
Attitudes and Professional Behaviors: Students should be able to:
1. appreciate the family’s concern and at times despair arising from the
development in an individual of altered mental status
TRAINING PROBLEM: ACUTE FEVER
Rationale
Acute fever is the most common presenting chief complains come to physician.
Indonesia has several endemic diseases such as dengue, typhoid, leptospirosis and
malaria. The ability to recognize acute fever, establish its diagnostic, and proper
management will decrease both morbidity and mortality.
A.
Knowledge: Students should be able to:
1. Describe and define principal pathophysiologic mechanisms of
 Dengue fever
 Typhoid fever
 Leptospirosis
 Malaria
2. Understand the clinical symptom and sign of
 Dengue fever
 Typhoid fever
 Leptospirosis
 Malaria
2. Understand understand the natural history of
 Dengue fever
 Typhoid fever
 Leptospirosis
 Malaria
3. Understand the complication of
 Dengue fever
 Typhoid fever
 Leptospirosis
 Malaria
4. Understand the principle management
 Fluid therapy
 Symptomatic therapy
 Antibiotic therapy
 Evaluation and monitoring
 Prevention
B.
Skills: Students should demonstrate specific skills including:
1. History-taking skills:
Student should be able to obtain, document, and present a medical history to
establish the diagnosis Acute fever and its complications.
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:
 General observation
 Vital sign
 HEENT
 Chest
 Abdominal



Neurologic
Musculosceletal
Skin
3. Differential diagnosis:
Student should be able to generate a prioritized differential diagnosis recognizing
specific history and physical exam finding that suggest a specific etiology.
 Dengue fever
 Chikungunya
 Leptospirosis
 Typhoid Fever
 Malaria
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.
Test:
 Dengue
o CBC : Thrombocyte, Hematocrite, Leukocyte
o Titer HI
o IgM, IgG anti Dengue (Elisa or dengue blot)
o NS 1
o Liver function test
 Typhoid
o CBC
o Widal
o Typhy dot
o Other serologic test
 Leptospirosis
o CBC
o Urinalisa
o Creatinine
o Serologic anti leptospira
o MAT leptospira
5. Communication skills: Students should be able to:
Explain the results of the evaluation to the patient, taking into consideration the
patient’s knowledge about his/her condition
Communicate the diagnosis, treatment plan, and prognosis of the disease to patients
and their families, and consider the patient’s knowledge of acute fever
and
preference regarding treatment and their complication.
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 Student should be able to access and utilize appropriate information
system and resources to help delineate issue related to acute fever.
 Student be able to manage fluid therapy
 Student be able to give symptomatic medication
 Student be able to give empiric treatment
 Student be able to give definitive treatment
 Student be able to monitor the treatment goal
 Student be able to recognize the complication
C.
Attitudes and Professional Behaviors: Students should be able to:
Student should be able to appreciate the importance of patient preferences
and compliances with management plan for those with acute fever and its
complication.
Appreciate the importance of side effects of medications and their impact on
quality of life and compliance.
Make appropriate referral to internal medicine consultant for special case of
acute fever in adult.
TRAINING PROBLEM: ANEMIA
Rationale
Anemia is a common condition, often identified incidentally in asymptomatic
patients. It can be “benign” or a manifestation of a serious underlying disease.
Distinguishing among the many disorders that cause anemia, not all of which are
treatable, is an important training problem for third year medical students.
Specific Learning Objectives
A. Knowledge: Students should be able to describe and define
the:classification of anemias
1. morphological characteristics, pathophysiology, and relative prevalence of:
a. iron deficiency and other microcytic anemias (i.e.,
b. sideroblastic)
c. macrocytic anemias
d. anemia of chronic disease
e. congenital disorders (sickle cell, thalessemias)
f. hemolytic anemias
2. available laboratory tests and normal values
3. indications, contraindications, complications of blood transfusion
4. steps in a critical pathway for anemia
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
a. constitutional symptoms (fatigue, weight loss)
b. GI bleeding
c. abdominal pain
d. drugs
e. diet
f. menstrual history
g. family history
2. physical exam skills: Students should be able to perform a physical exam
to establish the diagnosis and severity of disease including inspection of:
a. skin
b. eyes (sclera, conjunctiva, fundi)
c. mouth
d. heart
e. abdomen
f. rectum
g. lymph nodes
h. nervous syste
3. differential diagnosis: Students should be able to generate a list of the
most importance and most common causes of anemia, recognizing specific
history and physical exam findings that suggest a specific etiology of anemia.
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:
a. hemoglobin & hematocrit
b. red cell indices
c. reticulocyte count
d. iron studies (serum iron, TIBC, ferritin, transferrin)
e. serum B12 & folate
f. haptoglobin
g. LDH
h. Schilling test
i. hemoglobin electrophoresis
5. communication skills: Students should be able to: explain the results of an
initial evaluation to patients and their families, taking into consideration their
knowledge about the condition and 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)
6. basic procedural skills: Students should be able to perform and interpret:
a. peripheral blood smear
7. advanced procedural skills: Students should be able to assist in
perfoming:
a. bone marrow aspiration
8. management skills: Students should be able to develop an evaluation plan
to obtain appropriate diagnostic studies useful in establishing a specific
diagnosis including:
a. GI blood loss
b. hemolytic anemia
c. pernicious anemia
d. chronic disease (renal, thyroid, HIV, malignancy, inflammation)
e. Students should be able to develop a treatment plan for a specific
diagnosis including:
a. iron therapy
b. vitamin B12
c. folic acid
f. accessing and utilizing appropriate information systems and resources
to help delineate issues related to anemia
C. Attitudes: Students should be able to:
1. recognize that constitutional symptoms, such as fatigue or malaise, may be
caused by depression, rather than any underlying anemia or dietary
deficiency
TRAINING PROBLEM: ASTHMA
Rationale
Asthma is a major chronic obstructive airway problem that can be caused by
hypersensitivity. It is a serious public health problem. Asthma affects people of all
ages, ca be severe and is sometimes fatal.
Mastery of the approach to patients with asthma is important to general internists
because they often are the first physicians to see such patients. Moreover achieving
control of the disease is the primary goal.
Specific Learning Objectives
A.
Knowledge: Students should be able to:
1.
2.
3.
4.
Describe and define principal types of pathophysiologic mechanisms of asthma
Describe the exacerbation of asthma and underlying mechanism
List symptoms and signs indicative of an asthma and its variant
Describe the key diagnostic criteria for common causes of asthma, based on a
history, physical exam and laboratory testing
5. Identify the indications and the limitations of the following principal diagnostic
studies necessary to differentiate among common causes of asthma, including:
Chest X-ray
Pulmonary Physiological test
6. Describe steps in a critical pathway for patients with an asthma
7. Asthma management:
Define goal for successful asthma management
Avoid exposure or control asthma trigger (inciter, inducer)
Establish plan for management exacerbation
Home management
Hospital management
Medication for asthma
B.
Skills: Students should demonstrate specific skills including:
1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history.
Student should be able to obtain, document, and present a medical history to
establish the diagnosis and classification of asthma and severity of asthma
exacerbations.
 Episodic breathless
 Wheezing
 Chest tightness
 Seasonal variability of symptoms
 Nocturnal symptoms
 Family history of asthma
 Family history of another atopic disease
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:
 Awareness


Vital sign (increasing respiratory rate, tachycardia)
Examination of the head for
o Cyanosis
 Examination of the chest
o Hyperresonant on percussion
o Wheezing on auscultation
o Use of accessory muscle and intercostal recession
3. Differential diagnosis:
Student should be able to generate a prioritized differential diagnosis recognizing
specific history and physical exam finding that suggest a specific etiology.
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.
Test:
 Complete blood count
 Blood gas analysis
 Immunoglobulin E (IgE)
 Peak Flow meter
 Spirometry
5. Communication skills: Students should be able to:
Explain the results of the evaluation to the patient, taking into consideration the
patient’s knowledge about his/her condition
Communicate the diagnosis, treatment plan, and prognosis of the disease to patients
and their families, and consider the patient’s knowledge of asthma bronchial and
preference regarding treatment.
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 Student should be able to access and utilize appropriate information
system and resources to help delineate issue related to asthma bronchiale
 Student know medication that are used for relieving the symptom
 Student know medication that are used for controlling the disease
C.
Attitudes and Professional Behaviors: Students should be able to:
Student should be able to
Appreciate the impotance of patient preferences and compliances with management
plan for those with asthma bronchial
Appreciate the importance of side effects of medications and their impact on quality
of life and compliance
Make appropriate referral to pulmonology consultant for special case of asthma
TRAINING PROBLEM: CHEST PAIN
Rationale
Chest pain is an important presenting symptom for a variety of disorders, many of
which represent serious medical disorders. Angina pectoris is the most common
cardiac source of chest pain which may present classically or in a variant form such
as Prinzmetal angina or atypical angina. Distinguishing chest pain of cardiac origin
from that occurring as a result of chest wall disorders, pleuropulmonary disorders,
aortic dissection, gastrointestinal disorders, and psychogenic states is an important
training problem for third-year medical students.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. signs and symptoms of the following common causes of cardiac chest pain
a. angina pectoris (typical and atypical)
b. prinzmetal angina (variant angina)
c. acute myocardial infarction
d. unstable angina
e. non-ischemic cardiovascular pain
f. mitral valve prolapse
g. dissecting aortic aneurysm
h. pericardial pain (acute)
i. cardiomyopathy
2. signs and symptoms associated with chest pain due to GI disorders:
a. gastroesophogeal reflux
b. peptic ulcer disease
c. biliary colic
d. pancreatitis
3. signs and symptoms associated with chest pain due to pulmonary
disorders:
a. pneumonia
b. spontaneous pneumothorax
c. pulmonary embolism
d. pulmonary hypertension
e. inflammation of the pleura
4. signs and symptoms associated with chest pain due to musculoskeletal
causes:
a. costochondritis (Tietze’s syndrome)
b. muscular strain
5. reasons why the following factors are associated with exacerbating chest
pain:
a. anemia
b. hypoxemia
c. hypertension
d. tachyarrhythmia
e. hyperthyroidism
6. typical blood pressure values that occur with
a. aortic stenosis,
b. aortic insufficiency,
c. and pulsus paradoxicus
7. common abnormalities that can cause paradoxical and fixed splitting of
the S2; factors that increase or diminish the intensity of S1the
consequences of the following risk factors and their association with heart
disease:
a. hypertension
b. smoking
c. lipid abnormalities
d. age and gender
e. diabetes mellitus
f. family history of heart disease
g. obesity
h. dietary intake of saturated fat and cholesterol
i. sedentary lifestyle
8. role of a critical pathway or practice guideline in delivering high quality
care for patients hospitalized with ischemic chest pain
9. role of a critical pathway or practice guideline in delivery high quality, cost
effective care for outpatients presenting with non-ischemic chest pain
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among
etiologies of disease, including:
a. the presence of chest pain (typical, atypical)
b. dyspnea (resting, exertional, nocturnal)
c. history of hypertension, valvular heart disease, mitral valve
prolapse, rheumatic fever, cardiac murmurs, family history of heart
disease and cardiovascular risk factors
2. physical exam skills: Students should be able to perform a physical exam
to establish the diagnosis and severity of disease, including:
a. obtaining an arterial blood pressure
b. identifying major arterial and venous pulses for abnormalities and
the presence of any bruits
c. examination of the fundus
d. examining the extremities, to ascertain skin condition, including
color and temperature; presence of edema; cyanosis and presence
of clubbing
e. examining the lungs for crackles, rhonchi, and decreased breath
sounds
f. inspection and palpation of the anterior chest to identify right- and
left heaves and thrills
g. examining the heart, including rhythm; intensity of heart sounds;
presence of murmurs, rubs, gallops, or extra sounds (e.g., clicks).
h. Recognizes the following heart sounds:
i. S1, S2, and normal splitting of the S2
ii. abnormal sounds, S3, S4, summation gallop, abnormal
splitting of the S2 and mitral valve clicks
iii. distinguishes ejection from regurgitant systolic murmurs
and grade the murmurs.
i. examining the abdomen, to determine the presence of epigastric or
RUQ tenderness, hepatomegaly
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that suggest ischemic chest pain from nonischemic causes of
chest pain, (GI, pulmonary, musculoskeletal, or undetermined)
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.
a. Laboratory and diagnostic tests should include, when appropriate:
i. blood count
ii. specific enzyme tests to determine the presence of cardiac
damage
iii. electrocardiogram
iv. chest x-ray
v. ABG
b. students should be able to define the indications for and interpret
(with consultation) the significance of the results of:
i. echocardiogram
ii. exercise stress test and the use of the pretest probability of
CAD to interpret results
iii. stress thallium (myocardial perfusion radionuclide scan)
iv. cardiac catheterization
v. pulmonary angiography
vi. V/Q scan
5. communication skills:
a. Students should be able to facilitate the provision of counseling to
patients about the following:
i. smoking cessation
ii. dietary saturated fat and cholesterol reduction
iii. dietary sodium reduction
iv. weight reduction
v. increased physical activity
b. students should be able to communicate the diagnosis, treatment
plan, and prognosis of the disease to patients and their families,
and when appropriate, identify and educate patients about
cardiovascular risk factors for disease relative to their age and
gender
6. basic procedural skills: Students should be able to perform:
a. EKG
7. management skills: For each treatment listed below, students should be
able to identify indications, action, mechanism, side effects, adverse
reactions, and significant interactions of:
a. medications: students should be able to locate information on the
cost of various agents within each class of medications
i. digoxin
ii. calcium channel blockers
iii. beta blockers
iv. angiotensin-converting enzyme inhibitors
v. nitrates
vi. nitroglycerine
vii. aspirin
viii. heparin
ix. warfarin
b. other therapies:
i. thrombolytic therapy
ii. PTCA
c. surgical therapy:
i. CABG
8. students should be able to access and utilize appropriate information
systems and resources to help delineate issues related to chest pain
C. Attitudes and Professional Behaviors:
1. Students should be able to: understand the emotional impact of a
diagnosis of coronary artery disease and its potential effect on lifestyle
(work performance, sexual functioning, etc.)
TRAINING PROBLEM: COUGH
Rationale
Cough is a very common presenting complaint of patients. It is also an important
presenting symptom for a variety of disorders, some of which are serious and life
threatening. The most common causes of chronic cough are benign or self-limiting
problems, yet large resources may be expended to exclude life-threatening disease.
Recognizing the benign causes of cough and how they can be distinguished in a cost
effective way from serious causes, such as cancer and pneumonia, are important
training problems for third year medical students.
Specific Learning Objectives
A. Knowledge: Student should be able to define and describe:
1. the criteria used to classify a cough as chronic and a cough as productive
2. signs and symptoms associated with the most common causes of acute
cough:
a. viral tracheitis
b. bronchitis
c. pneumonia
3. signs and symptoms associated with the most common causes of chronic
cough:
a. post nasal drip
b. asthma
c. gastroesophageal reflux
d. cigarette smoking
e. lung cancer
f. TBC
g. CHF
4. signs and symptoms of variant asthma and its precipitants
a. the pathogenic, epidemiologic, and pathophysiologic differences
between:
b. community-acquired vs. hospital-acquired pneumonia
c. lobar vs. interstitial pneumonia
d. normal host vs. immunocompromised pneumonia
e. aspiration pneumonia vs. viral/bacterial pneumonia
5. the effect of old age on the pathogenic, epidemiologic and
pathophysiologic factors for each of the pneumonias listed above
6. the differences in pathogens and clinical presentation for chronic and
acute pneumonia
7. the pathophysiology of lung abscess, post-obstructive pneumonia, and
pseudotumor
8. the indications for pneumococcal and influenza immunization
9. the severe complications of acute bacterial pneumonia (bacteremia,
sepsis, emphysema, meningitis, metastatic microabscesses)
10.patients who are at risk for impaired or deficient immunity
11.the community health risks of undetected or inadequately treated
tuberculosis
12.the role of antibiotic control programs and other hospital basic support
systems in the case of patient’s pneumonia
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiology of disease, to:
a. obtain a thorough history of environmental/occupational allergies
and determine the likelihood of atopic disease
b. assess a patient for symptoms of gastroesphageal reflux disease
2. physical exam skills: Students should be able to perform a physical exam
to establish the diagnosis and severity of disease including:
a. respiratory rate, effect of breathing, level of respiratory distress
b. examination of the nasal cavity when possible
c. recognize the pharyngeal signs of post-nasal drip syndrome
d. distinguish crackles from rhonchi and wheezes
e. distinguish pleural effusion from pulmonary consolidation
f. identify the following by physical exam:
i. pleural effusion
ii. consolidation
iii. acute bronchitis
iv. interstitial lung disease
v. chronic obstructive diseases
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis including:
4. recognizing specific history and physical exam findings that both suggest
chronic rather than acute cough, and suggest a specific etiology of acute
cough
5. 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, when
appropriate, tests should include:
a. sinus CT examination
b. chest x-ray examination
c. barium swallow
d. cinesophagogram
e. gram stain of sputum
f. sputum culture and susceptibility reports
g. arterial blood gases
h. sputum cytology
i. acid fast stain of sputum (Zieht-Neelsen)
j. pulmonary function testing
k. cell count and chemistries of pleural fluid
6. communication skills: Students should be able to:
explain specific
treatment plans for the individual patient’s situation, counsel and educate
patients about:
a. environmental contributors to their disease
b. allergen skin testing
c. pneumococcal and influenza immunizations
d. smoking cessation
e. over the counter nasal decongestants sprays
7. basic procedural skills: Students should be able to perform:
a. arterial blood gas
b. sputum gram stain
8. management skills: Students should be able to design an appropriate
evaluation and treatment plan for patients including:
a. the treatment of post-nasal drip, allergic rhinitis, gastroesophageal
reflux, and variant asthma
b. suppressing cough, identifying the benefit and risks of cough
suppressant therapy
c. assessing atopic disease, including the indications for allergen skin
testing
d. identifying the presence of potential complications of bacterial and
viral pneumonias including:
i. respiratory failure
ii. meningitis
iii. bacteremia/sepsis
iv. empyema
v. pericarditis
vi. selecting appropriate antimicrobial therapy for:
vii. pneumococcal pneumonia
viii. hemophillus pneumonia
ix. aspiration/post-obstructive pneumonia
x. staphylococcal pneumonia
xi. mycoplasma pneumonia
xii. acute bronchitis
xiii. acute sinusitis
xiv. legionella
e. including locating information about the cost of alternative
regimens
9. accessing and utilizing appropriate information systems and resources to
help delineate issues related to cough
C. Attitudes and Professional Behaviors: Students should be able to:
a. demonstrate commitment to using cost-benefit considerations in the
selection of drug therapies for chronic cough, including over the
counter medications
b. appreciate the functional disruption of a patient’s life caused by these
illnesses
TRAINING PROBLEM: DYSURIA
Rationale
Dysuria is a very common symptom that is associated with significant morbidity
and is sometimes associated with serious medical disorders. Diagnosing the
etiology of dysuria is an important training problem for third year medical
students because accurate diagnosis requires prudent selection and interpretation
of common diagnostic studies. Also, learning the proper use of antibiotic therapy
for dysuria is important because of its impact on health care cost, on selection
pressure for antimicrobial resistance in the microbial pool of the community, and
on patient morbidity.
Specific Learning Objectives
A. Knowledge: Student should be able to define and describe:
1. the signs and symptoms, in women, of the following:
a. cystitis
b. urethral syndrome
c. estrogen deficiency changes
d. genital herpes
e. vaginitis
2. the signs and symptoms, in men, of the following:
a. urethritis
b. cystitis
c. genital herpes
d. balanitis
3. the signs and symptoms of the following:
a. urinary tract infection associated with Dysuria
b. pyelonephritis
c. prostatitis
d. asymptomatic bacteruria
4. the signs and symptoms of the following:
a. cystitis
b. urethritis
c. urethral syndrome
5. the typical presenting features that distinguish cystitis, pyelonephritis, and
urethritis from each other
6. the signs and symptoms of bacteremia and sepsis
7. factors that may predispose a patient to cystitis, pyelonephritis, urethritis,
and asymptomatic bacteruria including
a. sexual activity
b. pregnancy
c. barrier contraceptives (diaphragm)
d. prior urinary tract instrumentation
e. urinary catheterization (in-dwelling and intermittent)
f. anatomic anomalies (congenital and acquired)
g. bladder dysfunction
8. reasons why the following signs differentiate the causes of urinary tract
infection:
a. flank tenderness
b. enlarged kidney
c. palpable bladder
d. post-void residual urine
e. urethral discharge
9. the indications for the diagnostic tests for urinary tract infection including:
a. intravenous pyelogram
b. voiding cystourethrogram
c. urodynamic determination
d. renal ultrasound
10. the rationale for different durations of antimicrobial therapy for cystitis
and pyelonephritis
11. the commonly used antimicrobial drugs used for urinary tract infections
by:
a. naming six drugs and the class to which each belongs
b. describing the antimicrobial spectrum for each, and their
effectiveness
c. designating the cost of each
d. toxicity/side effects of each
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history:
a. that differentiates among etiology of disease including
eliciting a full description of symptoms which considers both
cystitis and non-cystitis causes of Dysuria
b. determining if dysuria is associated with sexual activity,
menstruation, or pregnancy
c. determining the patient’s risk for venereal disease.
d. obtaining a description of all prior episodes of dysuria and
how they were treated
e. determining the presence or absence of predisposing causes,
such as prior instrumentation, catheterization, and anatomic
anomalies
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
a. palpating the bladder for distention and tenderness
b. palpating and massaging the urethra to express a discharge
c. recognizing atrophic perineal changes, perineal inflammation,
balanitis
d. determining the presence or absence of flank tenderness
e. performing prostatic massage
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that suggest a specific etiology:
a. In women:
1. cystitis
2. urethral syndrome
3. estrogen deficiency atrophic changes
4. genital herpes
5. vaginitis
b. In men:
1. Urethritis
2. cystitis
3. genital herpes
4. balanitis
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
5. laboratory and diagnostic tests should include, when appropriate:
a. urinalysis, with recognition of pyuria, bacteria, white cell
casts, hematuria, renal tubular epithelial cells, and
transitional cells in the urine sediment
b. gram stain of urethral discharge
c. urethral swab culture
d. vaginal/cervical swab culture
e. KOH preparation of genital mucosal scrapings
f. urinary catheterization to assess for post-void residual
6. communication skills: Students should be able to:
a. counsel and educate patients about sexual activity.
b. communicate the diagnosis, treatment plan and subsequent
follow-up to patients.
7. basic procedural skills: Students should be able to perform:
a. urinalysis
b. gram stain of urethral discharge
c. urethal swab culture
d. KOH preps
e. urinary catheterization
8. management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patient including:
a. select appropriate antibiotic therapy prior to culture results
b. select the appropriate duration of therapy for cystitis and
pyelonephritis
c. identify information about costs of alternative treatment
regimens
d. access and utilize appropriate information systems and
resources to help delineate issues related to dysuria
C. Attitudes and Professional Behaviors: Each student should be able to:
appreciate the discomfort and concern associated with dysuria
TRAINING PROBLEM:FLUID, ELECTROLYTE & ACID-BASE DISORDERS
Rationale
Many disease processes can cause serious disturbances in the fluid, electrolyte and
acid-base status of patients. The general internist must be prepared to identify and
correct these disturbances as efficiently as possible.
Specific Learning Objective
A. Knowledge: Students should be able to define and describe:
1. pathophysiology
of
hypoand
hypervolemia,
hypoand
hypernatremia, hypo- and hyperkalemia, hypo- and hypercalcemia,
simple and mixed acid-base disorders, hypo- and hyperphosphatemia,
hypo- and hyper-magnesemia (respiratory acidosis & alkalosis, and
metabolic acidosis & alkalosis)
2. presenting symptoms and signs of the above disorders
3. the importance of total body water and its distribution
4. the differential diagnosis of hypo- and hypernatremia in the setting of
volume depletion, euvolemia and hypervolemia
5. how to identify spurious hyperkalemia or acidosis-related hyperkalemia
6. risks of too rapid or delayed therapy for hyponatremia
7. the most common causes of respiratory acidosis, respiratory alkalosis,
metabolic acidosis and metabolic alkalosis
8. calculate the anion gap and explain its relevance to determining the
cause of a metabolic acidosis
9. how to differentiate saline responsive from saline resistant metabolic
alkalosis
10.changes in total body water distribution that occur with aging
11.how altered mental status can contribute to electrolyte disorders
12.tests to use in the evaluation of fluid, electrolyte and acid-base
disorders
13.indications for obtaining an arterial blood gas
14.the types of fluid preparations to use in the treatment of fluid and
electrolyte disorders
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
a. 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.
b. 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.
c. 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,
2.
3.
4.
5.
6.
7.
8.
pulmonary disease, central nervous system disease and
malignancy).
physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
a. measurement of orthostatic vital signs
b. identify signs of volume overload including peripheral edema,
pulmonary edema, ascites
c. identify signs of volume depletion including tachycardia,
orthostatic hypotension, dry mucous membranes, poor skin
turgor
d. identify signs of sodium disorders including lethargy, weakness,
encephalopathy, delirium, seizures
e. identify signs of potassium disorders including weakness,
fatigue, constipation, ileus, cramping, tetany, hypo- or
hyperreflexia
f. identify signs of calcium disorders including cramping, tetany,
Chvostek’s & Trousseau’s sign, seizures, anorexia, constipation,
polyuria, hypo- or hyperreflexia, stupor, coma
differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that distinguish between:
a. hypo- and hypervolemia
b. hypo- and hypernatremia
c. hypo- and hyperkalemia
d. hypo- and hypercalcemia
e. hypo- and hyperphosphatemia
f. hypo- and hypermagnesemia
g. respiratory acidosis & alkalosis
h. metabolic acidosis & alkalosis
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, when appropriate, tests should include:
a. serum osmolality
b. urinary sodium
c. fractional excretion of sodium
d. anion gaps
e. ECG findings in hyper- and hypokalemia
communication skills: Students should be able to:
a. explain the results of the evaluation to the patient
basic and advanced procedure skills: Students should be able to:
a. insert a peripheral intravenous catheter
b. obtain an arterial blood gas
c. assist in the insertion of a central venous catheter
management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients including:
a. write appropriate fluid orders for the treatment of hypo- and
hypervolemia,
hypoand
hypernatremia,
hypoand
hyperkalemia, hypo- and hypercalcemia
b. write appropriate orders for replacing sodium, potassium,
calcium, phosphates, and magnesium
c. write appropriate orders for correcting hyperkalemia,
hypercalcemia, hyperphosphatemia and hypermagnesemia
d. calculate the water deficit that needs to be corrected to treat
hypernatremia
e. identify indications for administration of bicarbonate
f. explain to a patient why intravenous fluids are needed
g. access and utilize appropriate information systems and
resources to help delineate issues related to fluid, electrolyte
and acid-base disorders
TRAINING PROBLEM: JOINT PAIN
Rationale
Joint pain is a common problem that can cause considerable dysfunction and
disability. To properly evaluate and treat patients with joint pain, the general
internist must use a systematic approach.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. common presenting symptoms and signs of:
a. osteoarthritis
b. rheumatoid arthritis
c. systemic lupus erythematosus
d. polymyositis
e. crystalline arthropathies
f. scleroderma
g. carpal tunnel syndrome
h. herniated disc
i. aseptic necrosis of the hip
j. septic arthritis
k. sarcoidosis
2. the difference between arthralgia and arthritis
3. a systematic approach based on an understanding of pathophysiology
to classify potential causes of joint pain
4. key diagnostic criteria for common causes of joint pain
5. pathophysiology of joint stiffness and pain
6. immunologic tests to use in the evaluation of patients with joint pain
7. indications for performing an arthrocentesis
8. basic types of therapy to use in the treatment of joint pain and side
effects associated with each
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
a. eliciting features of a patient’s joint pain, including duration,
location, severity, timing, debility, exacerbating and remitting
factors, associated neurologic symptoms, impact on daily
activities, and prior or family history of related problems
b. determine when in the course of acute arthritis it is necessary
to obtain a sexual history and perform a genital exam with
appropriate cultures
c. determining the impact of joint pain on a patient’s activities of
daily living
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
a. performing a systematic examination of all joints, and
identifying the following abnormal findings:
i. erythema
ii. swelling
iii. tenderness
iv. effusion
3.
4.
5.
6.
7.
8.
v. crepitus
vi. decreased or excessive range of motion
vii. Heberden’s nodes
viii. Dupuytren’s contracture
ix. ulnar deviation
x. tophi
xi. synovial thickening
differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that suggest a specific etiology:
a. osteoarthritis
b. rhematoid arthritis
c. systemic lupus erythematosus
d. polymyositis
e. crystalline arthropathies
f. scleroderma
g. carpal tunnel syndrome
h. herniated disc
i. aseptic necrosis of the hip
j. septic arthritis
k. sarcoidosis
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:
a. joint fluid results (Gram’s stain, crystal exam, cell count &
differential, and glucose)
b. sedimentation rate
c. rheumatoid factor
d. complement levels
e. antinuclear antibodies
f. uric acid
g. complete blood count
h. plain x-rays
i. radionuclide bone scan
communication skills: Students should be able to explain the results of
the evaluation to the patient.
basic and advanced procedure skills: Students should be able to assist
in:
a. performing arthrocentesis of the knee after explaining the
procedure to the patient
management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patient including:
a. select appropriate medications to use for the relief of joint pain
b. locate information about the cost of alternative medications
c. determine when to recommend joint immobilization, rest,
nonsteroidal
antiinflammatory
drugs,
corticosteroids,
antibiotics, assistive devices (cane, walker), and physical
therapy
C.
d. determine when to involve a rheumatologist or surgeon in the
management of patients with joint pain
e. elicit questions from the patient about the management plans
f. access and utilize appropriate information systems and
resources to help delineate issues related to joint pain
Attitudes and Professional Behaviors: Students should be able to:
demonstrate sensitivity to the impact of chronic joint pain on a
patient’s quality of life and well-being
TRAINING PROBLEM: CONGESTIVE HEART FAILURE
Rationale
Chronic congestive heart failure ranks among the most common of cardiac problems.
Identification and correction of treatable underlying causes, elimination of
precipitating factors and judicious use of multidrug regiment for individuals with CHF
are important issues for third year medical students.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. types of processes (i.e. ischemic, valvular, cardiomyopathy,
infiltrative, inflammatory) and most common disease entities that
cause CHF
2. types of processes that cause systolic vs. diastolic dysfunction
3. signs and symptoms of left-sided vs. right sided heart failure
4. compensatory mechanisms in heart failure
5. factors leading to exacerbation of CHF including hypoxemia, anemia,
fever, hypertension, tachyarrhythmia, and hyperthyroidism
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including the presence or absence of the
following:
a. dyspnea
b. orthpnea
c. paroxysmal nocturnal dyspnea (PND)
d. peripheral edema
e. fatigue and decreased exercise tolerance
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
a. measurement of arterial blood pressure
b. assessment of major arterial pulses for abnormalities, including
bruits
c. assessment of eye ground changes, specifically of the
conjunctiva and retina
d. assessment of the extremities, to ascertain skin condition,
including color and temperature; presence of edema; cyanosis
and presence of clubbing
e. assessment of the lungs for crackles, rhonchi and decreased
breath sounds
f. inspection and palpatation of the anterior chest to identify
right- and left-sided heaves and thrills
g. assessment of the heart, including rhythm, intensity of heart
sounds, splitting of S2, and presence of murmurs, rubs,
gallops, or extra sounds (e.g., clicks)
h. assess abdomen, to determine the presence of hepatomegaly,
splenomegaly, hepatojugular reflux, ascites, abnormal masses,
pulsations, and bruits
3. differential diagnosis: students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that confirm or refute CHF distinguishing between:
4.
5.
6.
7.
8.
9.
a. pericardial
b. endocardial
c. valvular (congenital, acquired)
d. endocarditis
e. myocardial
f. hypertrophic
g. restrictive
h. congestive
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, when appropriate, should include:
a. chest x-ray
b. ECG baseline and during exercise testing
c. exercise testing (for functional capacity)
d. echocardiography (2D, TEE)
e. radionuclide gated blood pool scintigraphy (LVEF)
laboratory and diagnostic tests that one should be able to define the
indications for and interpret the results of include:
a. ECG baseline and during exercise testing
b. exercise testing (for functional capacity)
c. echocardiography (2D, TEE)
d. radionuclide gated blood pool scintigraphy (LVEF)
communication skills: Students should be able to:
a. communicate the diagnosis, prognosis and treatment plan of
the disease to patients and their families
b. educate patients about cardiovascular risk factors including:
i. hypertension
ii. smoking
iii. lipid abnormalities
iv. age and gender
v. diabetes mellitus
vi. family history of heart disease
vii. obesity
viii. dietary intake of saturated fat and cholesterol
ix. sedentary life style
x. alcohol
xi. Endocarditis prophylaxis
basic procedural skills: Students should be able to perform:
a. EKG
b. arterial blood gases
management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients including:
a. non-pharmacological management:
b. sodium restriction
c. physical activity
d. coronary revascularization
e. heart transplantation
f. pharmacologic management:
g. diuretics
h. vasodilators
i. positive inotropic agents
j. ACE inhibitors/ calcium channel blockers
k. antiarrhythmic agents
l. anticoagulants/antithrombotic agents
10.how critical pathways or practice guidelines in ambulatory patients or
patients hospitalized with CHF can be used to guide diagnostic test
ordering
11.accessing and utilizing appropriate information systems and resources
to help delineate issues related to CHF
C. Attitudes and Professional Behaviors: Students should be able to: recognize
the importance of lifestyle limitations caused by CHF (and counsel patients
appropriately)
TRAINING PROBLEM: COPD
Rationale
The chronic obstructive pulmonary diseases (chronic bronchitis/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 particular disorders make
them an important training problem for all third year medical students.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. disease entities and pathophysiologic processes of common, serious,
or prototypical respiratory diseases that can result in COPD
a. asthma
b. chronic bronchitis
c. emphysema
d. genetic predisposition—alpha 1 antitrypsin deficiency
2. other disease entities that may cause symptoms or signs similar to
those caused by COPD
a. allergic and non-allergic factors that may precipitate
bronchospasm and asthma
3. the risks for developing COPD in various patients and correlate risk
factors associated with each respiratory tract diseases with
occupational and environmental hazards
4. basic principles of O2, antibiotic, bronchodilator and corticosteroid
therapy
5. the scientific evidence supporting use of influenza vaccine/pneumovax
in COPD patients
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
a. existence, duration, and severity of the following symptoms:
i. shortness of breath
ii. sputum production
iii. cough
iv. wheezing
v. hemoptysis
vi. fever
vii. abnormal nocturnal/diurnal sleep patterns
b. patient’s occupational history, including current and past
exposures, environmental, smoking (active and passive),
travel, and family respiratory tract history, including:
c. a history of allergies, previous respiratory tract diseases, and
previous PPD, TB, and BCG status
d. the risk for alpha 1 antitrypsin deficiency
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease, including:
a. assessing the use of accessory muscles for breathing
b. inspection, palpation, percussion and auscultation of the chest
to:
i. recognize and differentiating abnormal lung sounds,
such as wheezing, rales, and rhonchi from normal
breath sounds.
ii. differentiate between a normal, dull and hyperresonant
chest by percussion.
iii. differentiate between areas of consolidation and pleural
fluid by assessing the quality of the breath sounds and
ancillary findings such as egophony and whispered
pectoriloquoy
iv. assess the presence of pleural friction rub.
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis, recognizing specific history and physical exam
findings that confirm or refute a diagnosis of asthma, chronic
bronchitis, or emphysema
4. laboratory interpretation: Students should be able to recommend when
to order diagnostic and laboratory tests and 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
5. laboratory and diagnostic tests, when appropriate, should include:
a. chest x-ray to recognize x-ray patterns that suggest asthma,
bronchitis, and emphysema
b. basic pulmonary function tests (such as ABG, pulmonary
function tests, and spirometry) used to evaluate respiratory
tract diseases
c. interpretation of a gram stain of sputum
d. pulse oximetry
6. communication skills: Students should be able to:
a. communicate the diagnosis, prognosis and treatment plan of
the disease to patients and their families, taking into
consideration their knowledge of the disease and their
treatment preferences
7. basic procedural skills: Students should be able to perform:
a. arterial blood gases
8. management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients including:
a. the basic principles of oxygen, antibiotic, bronchodialator, and
corticosteroid therapy
b. the basic bronchodialator and corticosteroid management when
appropriate
c. the steps in a critical pathway for patients hospitalized with
COPD exacerbations
d. smoking cessation strategies
e. accessing and utilizing appropriate information systems and
resources to help delineate issues related to COPD
C. Attitudes and Professional Behaviors:
1. Students should be able to: recognize that poor working, living, and
environmental conditions can contribute to respiratory tract disease
TRAINING PROBLEM: DIABETES MELLITUS
Rationale
Diabetes mellitus is, after obesity, the most common endocrinologic problem seen in
primary care practice. All physicians must identify those at risk and institute
appropriate management to ameliorate the potentially fatal complications of this
disease.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. presenting symptoms and signs of type I and type II diabetes mellitus
2. presenting symptoms and signs of diabetic ketoacidosis and nonketotic
hyperglycemic coma
3. major causes of morbidity and mortality in type I and type II diabetes
mellitus (e.g., coronary artery disease, peripheral vascular disease,
hypoglycemia, diabetic ketoacidosis, nonketotic hyperglycemic coma,
retinopathy, neuropathy, nephropathy, foot disorders)
4. pathogenesis, genetics, and epidemiology of type I and type II
diabetes mellitus
5. diagnostic criteria for type I and type II diabetes mellitus, based on a
history, physical examination, and laboratory testing
6. key laboratory tests needed to diagnose type I and type II diabetes
mellitus, diabetic ketoacidosis, nonketotic hyperglycemic coma, and
hypoglycemic coma including:
i. serum glucose
ii. electrolytes
iii. blood urea nitrogen
iv. creatinine, ketones (serum)
v. arterial blood gas
vi. glycosylated hemoglobin (HbA1C) or fructoseamine
vii. urine glucose, ketones, albumin/protein
7. goals of treatment of diabetes mellitus (i.e, preventing complications,
maintaining acceptable levels of glycemic control, and achieving
weight reduction, if obese)
8. key indications for diet therapy, oral hypoglycemic agents, and insulin
therapy in diabetes mellitus
9. management strategies for diabetic ketoacidosis and nonketotic
hyperglycemic states, including the similarities and differences in fluid
and electrolyte replacement
10.the American Diabetes Association (ADA) dietary recommendations for
type I and type II diabetes mellitus
11.the Somogyi effect and the dawn phenomenon, and the implications of
each in diabetes management
12.describe steps in the critical pathway for patients with diabetes
mellitus
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
weight gain or loss, polyuria,
polydypsia, polyphagia, weakness, fatigue, blurred vision, recent skin
2.
3.
4.
5.
6.
7.
8.
or other infection, vulvovaginitis/balanitis, abdominal pain, medication
history (e.g., corticosteroids, medication compliance), family history of
diabetes mellitus, and social history (e.g., cigarette use) disease
complications
(e.g.,
cardiac
symptoms,
autonomic
postural
hypotension, gastroparesis, diarrhea, constipation, urinary retention,
impotence, lower extremity pain, numbness) diet history (i.e., total
caloric intake, intake of sugar-containing foods, intake of saturated fat
and cholesterol, physical activity level, alcohol intake, timing of meals
in type I diabetes)
physical exam skills: Students should be able to perform, a physical
examination on patients with type I or type II diabetes mellitus to
establish the diagnosis and severity of disease focusing on altered
mental status, stupor, coma, Kussmaul respirations, fruity breath,
signs of autonomic insufficiency and/or volume depletion, skin
examination for diabetic dermopathy,
furuncles, carbuncles,
candidiasis, and necrobiosis lipoidica diabeticorum, cataracts,
retinopathy, glaucoma, peripheral pulses, peripheral neuropathy, corns
and calluses, dermatophytosis, ulceration
differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings, to diagnose type I versus type II diabetes
laboratory interpretation: Students should be able to recommend when
to order diagnostic and laboratory tests and 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:
serum glucose, electrolytes, blood urea nitrogen, creatinine, ketones,
arterial blood gas, glycosylated hemoglobin or fructosamine, urine
glucose, ketones, albumin, creatinine clearance, CBC with differential
and EKG
communication skills: Students should be able to: explain the results
of the evaluation to the patient
basic and advanced procedure skills: Students should be able to:
a. insert a peripheral venous catheter and obtain an arterial blood
gas, after explaining each procedure to the patient
b. perform fingerstick capillary blood glucose determination
c. assist in the insertion of a central venous catheter
management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients including:
a. writing appropriate fluid and insulin orders and outline critical
steps for the treatment of diabetic ketoacidosis and nonketotic
hyperglycemic coma
b. counseling a patient regarding basic features of ADA diabetic
diet recommendations
c. instructing a patient in home blood glucose monitoring
d. counseling a patient on behavior changes (e.g., smoking, poor
glycemic control, hypertension, hyperlipidemia and infection) to
avoid the complications of diabetes
e. determining when to institute diet therapy, oral hypoglycemic
agents, and insulin therapy
f. calculating an appropriate insulin dose for a diabetic patient
g. determining when to involve an endocrinologist in the care of a
diabetic patient
h. determining when to involve an expert in foot care and the
proper fitting of specially designed weight bearing shoes
i. accessing and utilizing appropriate information systems and
resources to help delineate issues related to diabetes
C. Attitudes and Professional Behaviors: Students should be able to:
a. appreciate the impact of diabetes mellitus on the individual and the
family
b. consider the individual’s social, socioeconomic, and cultural
background when designing nutritional recommendations and making
referrals
TRAINING PROBLEM: EVALUATION AND MANAGEMENT OF DYSLIPIDEMIAS
Rationale
Hypercholesterolemia 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 costeffective treatment strategies. It also draws attention to the importance of
community health education and nutrition
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. the contribution of hypercholesterolemia to coronary heart disease
(CHD) risk, including the importance of elevations in total cholesterol,
LDL cholesterol, HDL cholesterol, ratio of total to HDL cholesterol, and
lipoprotein subfractions
2. the classification of dyslipidemias, including who to screen, and how
often
3. 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 (see the Training Problem:
Healthy Patient)
4. the current National Cholesterol Education Program (NCEP) guidelines
for treatment of hypercholesterolemia
5. the therapeutic modalities for treatment of the common dyslipidemias,
including diet, exercise, cessation of smoking, and use of statins,
resins, and other agents; risks, benefits, expense, and how to choose
a program
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including obtaining pertinent history for diagnosis
of lipid disorders and presence of other cardiovascular risk factors,
including:
a. family history of early cardiovascular disease
b. dietary fat, saturated fat and cholesterol intake
c. smoking
d. alcohol use
e. presence of other CAD risk factors
f. presence of symptoms of angina and peripheral vascular
disease
g. past history of established CAD
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including
assessing for:
a. blood pressure elevation
b. xanthomata
c. atherosclerotic fundoscopic changes
d. carotid bruits
e. S4, single S2
f. femoral bruits
g. diminished peripheral pulses
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings that suggest primary or secondary causes of dyslipidemia.
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
5. laboratory and diagnostic tests, when appropriate, should include
a. lipoprotein fractions
b. TSH
c. serum glucose
6. communication skills: Students should be able to:
a. communicate the diagnosis, treatment plan and prognosis of
the disease to patients and their families.
b. tailor to the patient’s life-style and preferences, with emphasis
on the patient’s role in treatment and maximizing compliance.
c. address the lipid and cardiovascular risk problems in patient’s
family and community as well as on an individual basis.
7. management skills: Students should develop an appropriate evaluation
and treatment plan for patients including:
a. design a cost-effective treatment plan that incorporates the
NCEP recommendations, includes a program of dietary
modification, attends to cost considerations, and takes into
account the patient’s life-style
b. provide a detailed patient education regarding diagnosis,
prognosis and treatment plan
c. monitoring response to therapy and compliance, including liver
function in patients taking statin drugs, GI side effects in those
taking resins, and renal function and glucose in those using
niacin
d. outline a plan of exercise and weight reduction
e. accessing and utilizing appropriate information systems and
resources to help delineate issues related to Dyslipidemia
C. Attitudes and Professional Behaviors: Students should be able to:
a. appreciate the importance of encouraging patients to assume
responsibility for modifying their diet and increasing their exercise
level
b. appreciate the importance of treating asymptomatic patients at high
risk for CAD as aggressively as those with symptomatic disease
TRAINING PROBLEM: HIV INFECTION
Rationale
AIDS (acquired immunodeficiency syndrome) represents one of the most difficult
challenges in clinical medicine today. The majority of cases in the USA currently
occur among members of three risk groups (homosexual men, intravenous drug
users, and hemophiliacs who have received factory VIII concentrate in the past). The
remaining cases occur in either sexual partners of high risk individuals, infants born
of high risk mothers, or recipients of tainted blood products. Given there is not a
proven cure for this disorder, AIDS remains an important training problem for third
year medical students.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. CDC AIDS case definition
2. symptoms and signs of HIV-related opportunistic infections
a. P. carinii
b. Candidiasis
c. Cryptococcosis
d. Cryptosporidiosis
e. Cytomegalovirus
f. Mycobacterium avium complex
g. Mycobacterium tuberculosis
h. Toxoplasmosis
3. symptoms and signs of the following HIV-related malignancies:
a. Kaposi’s sarcoma
b. Non-Hodgkin’s lymphoma
c. Cervical carcinoma
4. what constitutes hospice care
5. relationship of CD4 count to opportunistic infections
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiology of disease including:
a. HIV infection risk factors:
i. sexual contacts
ii. parenteral exposure to infected blood by needle sharing
or transfusion
iii. occupational exposures
iv. other STDs that establish increased risk for HIV infection
b. HIV serology results and CD4 lymphocyte counts
c. HIV-related opportunistic infections.
d. fever, sweats, weight loss, wasting, dyspnea, diarrhea or
headache, neuropsychiatric complaints, vaginal candidiasis,
cervical dysplasia and neoplasia, or pelvic inflammatory
disease, travel
e. demonstrate the ability to obtain a diet history to assess:
i. number of meals eaten per day
ii. use of supplements
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including
assessing for:
a. lesions of Kaposi’s sarcoma
b. lymphadenopathy
c. retinitis
d. oral candidiasis
e. sinusitis
f. hairy leukoplakia
g. gingivitis
h. pulmonary infiltrates
i. pelvic inflammatory disease
j. mental status alterations
k. cognitive function deficits
l. focal neurologic deficits
m. muscle wasting of extremities and temporal muscles
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings in an HIV-positive patient who presents with:
a. fever
b. dypsnea
c. diarrhea
d. headache
e. altered mental status
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
5. laboratory and diagnostic tests should include, when appropriate:
a. specific tests for HIV (with appropriate application of sensitivity
and specificity)
b. hematologic abnormalities of HIV infection
c. CD4 lymphocyte count as a predictor of disease
d. induced sputum and LDH for the diagnosis of PCP
e. chest x-ray for P. carinii
f. serum and cerebral spinal fluid cryptococcal antigen
6. communication skills: Students should be able to:
a. counsel and educate patients about HIV exposure prevention
b. educate about HIV exposure and seroconversion rates
c. council and educate patients about complications of HIV drug
therapy
7. management skills: Students should be able to develop a treatment
plan for patients with HIV infection including:
a. prophylactic antiviral regimens for HIV positive persons
b. P. carinii prophylaxis.
c. assessing PPD status and treatment for TB
d. scheduling pneumococcal and H. influenza vaccines
e. ordering nutritional supplements to manage and prevent
malnutrition
f. identify community health resources available for the care of
AIDS patients
g. students should also be able to access and utilize appropriate
information systems and resources to help delineate issues
related to HIV infection
C. Attitudes: Students should be able to:
1. consider the bioethical and social issues concerning
confidentiality of HIV infection
2. understand and have tolerance towards alternative life styles
3. maintain a non-judgmental attitude
patient
TRAINING PROBLEM: ACUTE KIDNEY INJURY
Rationale
Acute kidney Injury (AKI), previously known as acute renal failure, has traditionally
been defined as the abrupt loss of kidney function that results in the retention of
urea and other nitrogenous waste products and in the dysregulation of extracellular
volume and electrolytes. The loss of kidney function is most easily detected by
measurement of the serum creatinine which is used to estimate the glomerular
filtration rate (GFR).
A.
Knowledge: Students should be able to:
Student should be able to:
Define and describe Acute Kidney Injury (AKI) and be able to distinguish between
the tree major pathophysiologic entity for AKI:
 Decrease renal perfusion (pre-renal)
 Intrinsic renal disease (renal)
 Acure renal obstruction (pos-renal)
o Bladder outlet obstruction (prostatic hyperthrophy)
o Stone, thrombus or tumor in ureter
 Distinguish major pathophysiologic etiology of pre renal AKI including:
o Hypovolemia
o Dcrease cardiac output (CHF, Tamponade)
o Systemic vasodilation (sepsis)
o Renal Vasoconstriction
 Distinguish major pathophysiologic etiologies of intrinsic renal ARF
including
o Vascular lesion
o Glomerular lesion
o Intersitial nephritis
o Drug and infection
 Intra-tubule deposition/obstruction
o Crystal, protein
 Acute tubular necrosis
o Ischemia
o Toxin
o Pigmen
 Discuss the natural history, initial evaluation and treatment and
complication of ARF
B.
Skills: Students should demonstrate specific skills including:
1. History-taking skills:
Bye the end of the clerkship student should be able to obtain, documentm and
present an age-appropirate history, that distinguishes among the three major
reason for AKI, including:
 Pre-disposing condition
 Nephrotoxic drugs or agents
 Systemic disease
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:



The determination of a patient’s volume status through estimation of the
central venous pressure the height of jugular venous distension and
measurement of pulse and blood pressure.
Palpation and percussion of the bladder to recognize bladder distention
Examination for evidence of systemic disease, including
o Skin, joints, and nails
3. Differential diagnosis:
Student should be able to generate a prioritized differential diagnosis recognizing
specific history and physical exam finding that suggest a specific etiology.
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.
 The recognition of cast, red blood cells, white blood cells, and crystal
 RIFLE criteria base on elevated creatinine, and urine output
 Calculate fractional excretion of sodium and appreciate its usefulness in
distinguishing between pre-renal and intrinsic renal disease.
 Students should be able to recommend when each of these test should be
ordered
5. Communication skills: Students should be able to:
Explain the results of the evaluation to the patient, taking into consideration the
patient’s knowledge about his/her condition
Communicate the diagnosis, treatment plan, and prognosis of the disease to patients
and their families, and consider the patient’s knowledge of diabetes mellitus and
preference regarding treatment especially renal supporting therapy (hemodialysis).
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 Student should be able to access and utilize appropriate information
system and resources to help delineate issue related to acute kidney
injury
 Fluid therapy: volume management
 Measuring CVP
 Discontinuing renal toxin
 Electrolyte monitoring
 Electrolyte management (hyperkalemia)
 Indication for acute dialysis (fluid overload, hyperkalemia, acidosis,
complication of uremia – altered mental status, bleeding, pericarditis,
myopathy)
C.
Attitudes and Professional Behaviors: Students should be able to:
Student should be able to appreciate the importance of patient preferences
and compliances with management plan for those with diabetes mellitus and
its complication.
Appreciate the importance of side effects of medications and their impact on
quality of life and compliance.
Make appropriate referral to nephrology consultant for special case of acute
kidney injury.
TRAINING PROBLEM: 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) and stroke- as well as renal disease, 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.
Specific Learning Objectives
A. Knowledge: Students should be able to:
1. identify the etiologies and relative prevalence of primary and
secondary hypertension
2. define hypertensive urgency and emergency, citing examples of both
3. describe signs and symptoms of the following presenting disorders
associated with secondary hypertension:
a. polycystic kidneys
b. renovascular hypertension
c. Cushing’s disease or syndrome
d. Pheochromocytoma
4. define and describe the manifestations of target-organ disease due to
hypertension
5. define the classification of blood pressure (systolic blood pressure
(SBP), diastolic blood pressure (DBP)) for all age 18 or older (young
adult, middle age, and the elderly)
6. describe 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
7. describe the prevention strategies for reducing hypertension (including
lifestyle factors, dietary intake of sodium, weight, and exercise level),
and explain the physiologic basis and/or scientific evidence supporting
each strategy
8. describe steps in a critical pathway for management of patients with a
hypertensive emergency
B. Skills: Students should demonstrate specific skills including:
 history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
 duration and levels of elevated blood pressure
 history of symptoms of cardiovascular, cerebrovascular, or
renal disease; diabetes; dyslipidemia; or gout
 history of symptoms suggesting secondary hypertension (see
knowledge section, A:3)
 history of weight gain, leisure-time physical activities, smoking
or other tobacco use
 family history of high blood pressure, premature CHD, stroke,
CVD, diabetes mellitus and Dyslipidemia






psychosocial and environmental factors that may elevate blood
pressure
 dietary assessment including sodium intake, alcohol use and
intake of saturated fat and cholesterol results and side effects
of previous antihypertensive therapy
 use of commonly prescribed, over-the -counter, and illicit
medications that may raise blood pressure or interfere with the
effectiveness of antihypertensive medications
physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease, including:
 blood pressure measurements to detect and confirm the
presence of high blood pressure
 examination of the fundus for arteriolar narrowing,
arteriovenous nicking, hemorrhages, exudates or papilledema
 neck for carotid bruits, distended veins or an enlarged thyroid
gland
 heart for increased rate, increased size, precordial heave,
clicks, murmurs, arrhythmias, and third(S3) and fourth (S4)
sounds
 abdomen for bruits, enlarged kidneys, masses, and abnormal
aortic pulsation
 extremities for diminished, delayed, or absent peripheral
arterial pulsations, bruits, and edema
 peripheral pulses specifically femoral arterial pulses
 body habitus, looking for changes associated with secondary
hypertension
 peripheral and central nervous system for ischemic changes
differential diagnosis: Generate a prioritized differential diagnosis
recognizing specific history and physical exam findings that suggest a
specific etiology.
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:
 urinalysis
 complete blood count
 blood glucose (fasting if possible)
 potassium
 calcium
 creatinine
 uric acid
 cholesterol, HDL, LDL, and triglycerides
 electrocardiography
communication skills: Students should be able to communicate the
diagnosis, treatment plan and prognosis of the disease to patients and
their families, taking into account the patient’s knowledge of
hypertension and his/her preferences regarding treatment options
educate patients about hypertension risk factors, taking into account:
 demographics
 concomitant diseases and therapies
 quality of life
 physiologic and biochemical measurements
 economic considerations
 basic procedural skills: Skills that students should be able to perform:
 urinalysis (dipstick and microscopic)
 EKG
 management skills: Students should develop an appropriate evaluation
and treatment plan for patients with:
 acute and chronic hypertension
 primary hypertension
 secondary hypertension
 students should be able to access and utilize appropriate
information systems and resources to help delineate issues
related to hypertension.
 students should be able to prescribe preventive strategies to
diminish hypertension, including:
i. weight reduction
ii. moderation of alcohol intake
iii. regular physical activity
iv. reduction of sodium intake
v. increase in potassium intake
vi. smoking cessation
C. Attitudes and Professional Behaviors: Students should be able to:
1. appreciate the importance of patient preferences and compliance with
management plans for those with hypertension
2. appreciate the importance of preventive strategies may diminish need
for medications
3. appreciate the importance of complications secondary to drug
administration, to which the geriatric population in particular may be
more prone
LEARNING OBJECTIVE: 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 an
expected physician behavior for the comprehensive care of the adult. Selecting and
performing an appropriate smoking cessation intervention is an important training
problem for the third year medical student.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. the pharmacological effects of nicotine
2. nicotine withdrawal symptoms
3. intervention strategies that physicians can use for their patients
4. symptoms indicating nicotine dependence
5. the common barriers preventing patients from undertaking smoking
cessation
6. the principles of at least one theory of behavior modification
7. the common medical diseases associated with chronic smoking and the
effects of stopping on future risk.
8. the indications for nicotine replacement therapy
9. the association between smoking cessation and weight gain
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease, in order to:
a. determine if a patient has nicotine dependence
b. assess a patient’s motivation for stopping
c. assess the patient’s past experiences with smoking cessation
d. review and determine patient’s barriers to stopping
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
a. identifying nicotine stains on physical exam
b. identifying lesions with malignant potential on the lips and in
the oral cavity
c. identifying the chest findings consistent with chronic obstructive
lung disease
3. communication skills: Students should be able to:
a. demonstrate a commitment to administer a non-judgmental
“stop smoking” message to every patient who smokes
b. respond positively and non-judgmentally to patient’s excuses or
concerns about cessation
c. counsel a patient on smoking cessation
d. promote problem-solving by the patient
4. management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patient including:
a. design an intervention that matches the stage of behavior
change demonstrated by the patient
b. explain how to use nicotine patch therapy and nicotine gum
therapy
c. negotiate a follow-up plan with the patient
d. encourage the patient to increase physical activity to lessen
weight gain, if medically appropriate.
e. access and utilize appropriate information systems and
resources to help delineate issues related to smoking cessation
C. Attitudes and Professional Behaviors: Student should be able to:
administer a non-judgmental “stop smoking” message to every patient who
smokes
TRAINING PROBLEM: SUBSTANCE ABUSE
Rationale
Alcohol and drug abuse are associated with many of the interactions internists have
with patients in a given day. The effects of substance abuse extend beyond the
individual to include family, co-workers, and friends, yet can often be hidden from
the observer who is unaware of their ubiquity. The physician who knows how to
observe and ask about substance abuse can, through appropriate therapy,
treatment, and/or referral, help the patient return to a healthy lifestyle.
Specific Learning Objectives
A. Knowledge: Students should be able to describe:
1. presenting signs and symptoms of abusing the following substances:
alcohol, opiods, cocaine, amphetamines, hallucinogens, barbiturates,
and other related medications and benzodiazipines.
2. presenting symptoms of alcohol and drug intoxication.
3. presenting symptoms of alcohol and drug overdose.
4. presenting symptoms of acute alcohol and drug withdrawal.
5. key risk factors for alcohol and drug abuse (social, genetic).
6. the major causes of morbidity and mortality associated with substance
abuse (e.g., trauma, motor vehicle accidents, homicide, overdose,
cirrhosis, endocarditis, HIV, hepatitis B, and suicide).
7. discuss the differences among substance abuse, dependency, and
addiction.
8. the diagnostic criteria for alcohol and drug abuse, dependency, and
addiction, based on a history, physical examination, and laboratory
testing.
9. questions in the CAGE questionnaire (“Have you ever felt you should
Cut down on your drinking?”, “Have people Annoyed you by criticizing
your drinking?”, “Have you ever felt bad or Guilty about your
drinking?”, “Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hang-over [Eye-Opener]?”)*.
10.list the key laboratory tests useful in evaluating substance abuse (e.g.,
blood alcohol level, liver function tests, complete blood count,
amylase, urine and serum drug screens)
11.list available community referral sources (e.g., Alcoholics Anonymous,
Narcotics Anonymous) and where to obtain telephone numbers.
12.list the key health benefits that accrue with cessation.
13.describe the management strategies for acute alcohol and drug
withdrawal.
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
a. eliciting a social history in a nonjudgmental, supportive
manner, using appropriate questioning (CAGE questions, etc.).
b. evaluating a patient using the Diagnostic and Statistical Manual
of Psychiatric Disease (DSM III-R) criteria for substance or
alcoholic dependence.
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease including
assessing in a substance-abusing patient for:
a. fever
b. hypertension
c. tachycardia
d. skin for jaundice, needle tracks, manifestations of endocarditis,
HIV infection, and cirrhosis
e. eyes for pupil size and icterus, fundus exam (roth spots)
f. nose for nasal septum perforation
g. mouth for odor of alcohol and parotid enlargement
h. breasts for gynecomastia
i. lymph nodes for adenopathy
j. heart for murmurs
k. abdomen for hepatomegaly
l. genital exam for testicular atrophy
m. neurologic exam for tremor and cognitive impairment
n. Dupuytren’s contractures
3. differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings to determine the diagnosis of substance abuse of drugs or
alcohol.
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
5. laboratory and diagnostic tests should include, when appropriate:
a. blood alcohol level
b. urine and serum toxicology screens
c. complete blood count
d. liver enzymes
e. amylase and lipase
f. HIV
6. communication skills: Students should be able to explain the results of
the evaluation to the patient.
7. management skills: Students should be able to:
a. assess a patient’s motivation for achieving sobriety/abstinence.
b. deliver a directed, non-judgmental message to a substanceabusing patient urging him/her to quit.
c. make an appropriate community referral for a substanceabusing patient
d. write appropriate fluid and medication orders for the treatment
of acute alcohol and/or drug withdrawal.
e. access and utilize appropriate information systems and
resources to help delineate issues related to substance
abuse.
C. Attitudes and Professional Behaviors: Students should be able to:
1. recognize the biopsychosocial etiology of addictions
2. appreciate the prevalence of addictions and the need to consistently
include substance abuse in the history.
3. appreciate the power of simple directed messages in stimulating
behavior change.
4. recognize that substance abuse affects the community and family, as
well as the patient.
5. demonstrate a commitment to non-judgmental care of substanceabusing patients
 [Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 252:
1905, 1984.]
TRAINING PROBLEM: THE WORKUP OF 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., breast, skin, colon, lung, prostate) is an excellent means of
sharpening 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 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
treatment.
Specific Learning Objectives
A. Knowledge: Students should be able to define and describe:
1. principal clinical presentations, clinical courses, complications, and
causes of death for the most common cancer
2. basic methods of initial evaluation, including the sensitivity and
specificity of basic diagnostic studies and indications for their use,
including:
a. indications for skin biopsy in a patient with a suspicious skin
lesion
b. indications for breast biopsy in a person with a breast nodule or
abnormal screening mammogram
c. indications for a lymph node biopsy in a person with isolated
lymphadenopathy
d. initial cost-effective workups for: isolated pleural effusion,
pulmonary nodule, liver nodule, prostate nodule, elevated PSA,
testicular nodule, stool test positive for occult blood, abnormal
PAP smear, testicular nodule, and other findings suggestive of
gastrointestinal and urogenital cancers
e. indications for sigmoidoscopy, barium enema, and colonoscopy
in individuals at risk for colon cancer
B. Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
a. skin cancer
b. breast nodules and secondary signs of breast cancer
c. lymphadenopathy
d. pulmonary nodule
e. prostate cancer
f. colon cancer
2. physical exam skills: Students should be able to perform a physical
exam to establish the diagnosis and severity of disease, including
assessing for:
a. common skin cancers
b. breast nodules and secondary signs of breast cancer
c. lymphadenopathy
d. pleural effusion
3.
4.
5.
6.
7.
8.
9.
e. liver nodularity and enlargement
f. prostatic nodule
g. testicular nodule
h. pelvic mass
i. cervical erosion
cost-effectively designs and carries out the initial diagnostic and
staging workup, which includes ordering and interpreting, when
appropriate:
a. skin biopsy
b. breast imaging and biopsy
c. lymph node biopsy
d. chest CT and pleural fluid analysis
e. upper and lower GI imaging and endoscopy
f. abdominal CT and ultrasound
g. prostate and testicular ultrasounds and biopsy
h. alkaline phosphatase/acid phosphatase/PSA
i. liver biopsy
j. bone scan
k. Pap smear
differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam
findings to:
a. provide prompt and critical review of the findings of the initial
evaluation
b. establish a tentative diagnosis and estimate severity and
prognosis by use of staging criteria
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 for test cost and performance
characteristics, as well as patient preferences
laboratory and diagnostic tests should include, when appropriate:
selecting tests carefully to minimize the risks of false-positive and false
negative results
communication skills: Students should be able to:
a. communicate the working plans, diagnosis, treatment plan and
prognosis of the disease to patients and their families in a clear
and supportive manner for bearing bad news
b. provide a concise oral and written presentation of clinical
findings, assessment, and initial diagnostic plan to faculty
preceptor
basic procedural skills: Skills that students should be able to perform:
a. chest tap for pleural fluid analysis*
b. cervical PAP smear
c. stool occult blood testing
management skills: Students should develop an appropriate evaluation
and treatment plan for patients with cancer including:
a. provision of support and information to patient, and
coordination of care for work-up
b. timely arrangement of pertinent consultations
c. accessing and utilizing appropriate information systems and
resources to help delineate issues related to common cancers
C. Attitudes and Professional Behavior: Students should appreciate the
importance of:
1. keeping the patient well-informed and well-supported
2. maintaining close collaboration and coordination with specialty
consultants
3. maintaining responsibility for coordinated care and support of the
patient
4. being able to discuss DNR status with a patient and family
TRAINING PROBLEM: NEPHROTIC SYNDROME
Rationale
Nephrotic syndrome is kidney disease with proteinuria, hypoalbuminemia and edema
with many specific causes. Nephrotic syndrome can also result from systemic disease
that affect other organs in addition to the kidney such as diabetes, amyloidosis,
hypertension and lupus erythematosus. Mastery the approach to patients with
nephrotic syndrome is important to general doctor because they will be the first
physician to see such patient and they should know when to treat or to refers a
patients to internists or nephrologist
Specific Learning Objectives
A. Knowledge: students should be able to:
1. Describe and define the definition of nephrotic syndrome
2. Describe and define the patophysiologic mechanism of nephrotic
syndrome
3. Describe and define the classification of nephrotic syndrome
4. Describe the criteria for diagnosing nephrotic syndrome based on history,
physical examination and laboratory testing
5. Define the complications of nephrotic syndrome
B. Skills:
1. History taking: students should be able to obtain, document and present
a medical story to establish the diagnosis of nephrotic syndrome and the
probability of the etiology based on its classification
2. Physical examination skills: students should be able to perform a
physical examination to establish the diagnosis including :
 General observation
 Vital sign
 Lymph nodes
 Abdominal examination
 Extremitas examination
3. Differential diagnosis: students should be able to generate the causes
of nephrotic syndrome and recognizing the spesific history and physical
examination that suggest a specific etiology of nephrotic syndrome.
4. Laboratory interpretation: students should be able to recommend when
to order diagnostic laboratory tests and interpret them including
consideration of test cost and performance characteristics as well as
patients preference. Laboratory and diagnostic test should include, when
appropriate:
a. Urine analysis
b. 24-h urine for protein
c. Ceratinin clearance
d. Serum albumin
e. Cholesterol
f. Complement
g. Urine protein electrophoresis
h. Blood glucose
i. ANA (anti nuclear antibody)
5. Communication skills: student should be able to explain the initial result
to the patients and their families taking into the consideration their
knowledge about the condition and counsel with regard to:
 Possible causes
 Appropriate further evaluation to establish the diagnosis of an
underlying disease
6. Management skills: students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 Student know medication that are used for relieving the symptom
 Student know when and how to refers to internist/nephrologist
C. Attitude and proffesional behaviour: students should be able to: students
should be able to appreciate the importance of patients preferences and
compliances with management plan and make a approriate refferal to
nephrologist.
TRAINING PROBLEM: CHRONIC KIDNEY DISEASE
Rationale: Chronic kidney disease (CKD) encompasses a spectrum of different
pathophysiologic process associated with abnormal kidney function and a
progressive decline in glomerular filtration rate (GFR). Mastery in approach to
chronic kidney disease is important to general doctor because they are the first
physician that see such patients and they should be able to making the right
diagnosis and or manage the threatening life complications.
Specific Learning Objective
A. Knowledge: students should be able to:
1. Describe and define the definition of chronic kidney disease
2. Identifying patients at risk for developing chronic kidney disease
3. Describe and define the classification of chronic kidney disease
4. Describe and define the patophysiology of chronic kidney disease
5. Describe and define the etiology of chronic kidney disease
6. Describe and define the criteria for diagnosing chronic kidney disease
7. Describe and define the complications of chronic kidney disease
8. Describe and define the treatment including dietary intervention, drug
therapy, indication for dialysis and renal replacement therapy
B. Skills: students should be able to demonstrate specific skills
including:
1. History taking skills: student should be able to obtain, document and
present an age-appropriate medical history that differentiates among
etiologies of the disease, including: hypertension, diabetes mellitus,
glomerulonephritis,
polycystic
kidney
disease,
viral-associated
nephropathy (HIV, Hepatitis) and drugs.
2. Physical examination skills: students should be able to perform a physical
exam to establish the diagnosis and severity of disease including:
 General observation
 Vital sign
 Eye
 JVP
 Chest
 Abdominal
 Skin
 musculoskeletal
3. Differential diagnosis: students should be able to generate a differential
diagnosis of chronic kidney disease, establish the chronicity and disproving
a major acute component.
7. Laboratory interpretation: student should be able to recommend when
and what to order diagnostic and laboratory tests and be able to interpret
them including considertaion of tests cost and performance characteristic
as well as patient preference laboratory and diagnostic tests. Laboratory
and diagnostic test should include, when appropriate:
a. Hemoglobin
b. Ureum, creatinin, creatinin clearance, GFR
c. Electrolyte including natrium, kalium, chlor, phosphate, calcium
d. Urinanalysis
e. 24-h urine for protein
f. Serum albumin
g. Blood gas analysis
4. Communication skills: students should be able to:
 Explain the results of the evaluation to the patients taking into
consideration the patient’s knowledge about their condition
 Communicate the diagnosis, treatment plan and prognosis of the
disease and educate patient about his/her disease
5. Management skills: students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 Students able to educate patient about controlling his/her risk
factor for chronic kidney disease, including diet and drugs
 Students able to recognize the complication and know when and
how to refers to nephrologist
C. Attitudes and professional behaviours: students should be able to
students should be able to appreciate the importance of patients preferences
and compliances with management plan and make a approriate refferal to
nephrologist.
TRAINING PROBLEM: DYSPEPSIA
Rationale: Dyspepsia refers to a chronic or reccurent pain in the upper
abdomen, upper abdominal fullness and feeling full earlier than expected when
eating. General doctors should mastering the approach and treatment for
dyspepsia because in general practice dyspepsia is the common symptom.
Specific Learning Objective
A. Knowledge: students should be able to:
1. Describe and define the definition of dyspepsia
2. Describe and define the symptoms of dyspepsia
3. Describe and define the alarm signals of dyspepsia
4. Describe and define the differential diagnosis for dyspepsia
5. Identify the indication and limitations of the following principal diagnostic
studies neccesary to differentiate among common cause of dyspepsia
including: abdominal ultrasonography, upper GI endoscopy and biopsy,
and tested for the presence of H. pylori
6. Describe and define the management of dyspepsia including nutrition
intervention, empirical therapy and symptomatic therapy.
B. Skills:
1. History taking skill: students should be able to obtain, document and
present an age-appropriate history medical history that distiguish
functional dyspepsia and dyspepsia with alarm signals. Alarm signals is
the presence of dysphagia, odynophagia, unexplained weight loss,
reccurent vomiting leading to dehydration, occult or gross bleeding, a
palpable mass or adenopathy, or age >45 years old.
2. Physical exam skill: students should be able to perform a physical
examination to establish the diagnosis of dyspepsia, including abdominal
exam and perform an adequate exam for finding the alarm signals such as
rectal exam, lymph node exam (as indication)
3. Differential diagnosis: students should be able to generate a differential
list of dyspepsia including GERD, Irritable bowel syndrome, upper GI
malignancy, liver disease, pancreatic disease or appendicitis.
4. Diagnostic and 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’s cost and performance characteristic as well as
patient preferences. Laboratory test and diagnostic should include, when
appropriate:
 Hemoglobin.
 Liver function test
 Amylase and lipase
 Abdominal ultrasonography
 Upper GI endoscopy and biopsy
 Test for the presence of H.pylori
5. Communication skill: students should be able to communicate the
diagnosis, treatment plan and prognosis of the disease to patients and
their family, taking into account the patient’s knowledge and their
preferences regarding treatment option.
6. Management skill: students should be able to develop an appropriate
evaluation and treatmet plan for patients, including:
 Nutritional intervention
 Symptomatic therapy
 When to prescribe empirical therapy.
C. Attitude and professional behaviors:
 Students should be able to: know when and how to make appropriate
refferal to gastroenterologist consultant for patients with alarm signals

Students should recognize the importance of patient preference when
selecting among treatment option.
TRAINING PROBLEM: CIRRHOSIS
Rationale
Cirrhosis is the development of liver fibrosis to the point that there is architectural
distortion with the formation of regenerative nodules, which results in decreased liver
function. Cirrhosis is defined histopathologically and has a variety of causes, clinical
features and complications. Cirrhosis can be caused by various etiology, which also
affect its management.
A. Knowledge: Students should be able to define and describe:
1. the possible causes of cirrhosis, such as alcoholism, chronic viral hepatitis,
autoimmune hepatitis, biliary cirrhosis, cardiac cirrhosis, inherited
metabolic liver disease and cryptogenic cirrhosis
2. the symptoms of cirrhosis such as anorexia, nausea, vomiting, diarrhea,
vague RUQ pain, fatigue, weakness, fever, jaundice, amenorrhea,
impotence, infertility and signs of cirrhosis such as spider telangiectases,
palmar erythema, jaundice, scleral incterus, parotid and lacrimal gland
enlargement, clubbing fingers, Dupuytren’s contracture, gynecomastia,
testicular atrophy, hepatosplenomegaly, ascites, gastrointestinal bleeding,
hepatic encephalopathy.
3. the available diagnostic studies and their use according to the possible
causes of cirrhosis such as serum viral hepatitis markers (HBsAg, antiHBc, anti-HBs, anti-HCV), peripheral blood count, albumin, prothrombin
time, activated partial thromboplastin time, international normalized ratio
(INR), abdominal ultrasound, CT or MRI scan and liver biopsy.
4. the Child-Pugh scoring system to predict severity and the risk of
complications.
B. Skills: Students should demonstrate specific skills including:
1. History-taking skills:
Bye the end of the clerkship student should be able to obtain, document and
present an age-appropirate history, that distinguishes among possible causes for
cirrhosis, including:
o alcoholism
o chronic viral hepatitis
o autoimmune hepatitis
o biliary cirrhosis
o cardiac cirrhosis
o inherited metabolic liver disease
o cryptogenic cirrhosis
and the symptoms of cirrhosis including
o anorexia
o nausea
o vomiting
o diarrhea
o vague RUQ pain
o fatigue
o weakness
o fever
o jaundice
o amenorrhea
o impotence
o infertility
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of cirrhosis including:
o spider telangiectases
o palmar erythema
o jaundice
o scleral incterus
o parotid and lacrimal gland enlargement
o clubbing fingers
o Dupuytren’s contracture
o gynecomastia
o testicular atrophy
o hepatosplenomegaly
o flapping tremor
and complications of disease
o portal hypertension
 gastroesophageal varices
 portal hypertensive gastropathy
 splenomegaly
 ascites
 spontaneous bacteriaal peritonitis
o hepatorenal syndrome
 type 1
 type 2
o hepatic encephalopathy
o hepatopulmonary syndrome
o portopulmonary syndrome
o malnutrition
o caogulopathy
 factor deficiency
 fibrinolysis
 thrombocytopenia
o bone disease
 osteopenia
 osteoporosis
 osteomalacia
o hematologic abnormalities
 anemia
 hemolysis
 thrombocytopenia
 neutropenia
3. Differential diagnosis:
Student should be able to generate a prioritized differential diagnosis recognizing
specific history and physical exam finding that suggest a specific etiology.
4. Diagnostic and 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.
 serum viral hepatitis markers (HBsAg, anti-HBc, anti-HBs, anti-HCV),
 peripheral blood count


albumin
prothrombin time (PT), activated partial thromboplastin time (APTT),
international normalized ratio (INR)
 abdominal ultrasound
 CT or MRI scan
 liver biopsy
 students should be able to recommend when each of these test should be
ordered
5. Communication skills: Students should be able to:
 explain the results of the evaluation to the patient, taking into
consideration the patient’s knowledge about his/her condition
 communicate the diagnosis, treatment plan, and prognosis of the disease
to patients and their families, and consider the patient’s knowledge of
cirrhosis and preference regarding treatment symptomatically to liver
transplant.
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 provision of support and information to patient, and coordination of care
for work-up
 accessing and utilizing appropriate information systems and resources to
help delineate issues related to common cirrhosis
 decide which patient needs to be admittted to inhospital care
 fluid therapy & volume management
 electrolyte monitoring and management
7. Basic procedural skills: Skills that students should be able to perform:
 ascites tapping
C.
Attitudes and Professional Behaviors: Students should be able to:
 Student should be able to appreciate the importance of patient
preferences and compliances with management plan for those with
cirrhosis and its complication.
 Appreciate the importance of side effects of medications and their impact
on quality of life and compliance.
 Make appropriate referral to gastroenterology and hepatology consultant
for special case of cirrhosis and its complications.
TRAINING PROBLEM: UPPER GASTROINTESTINAL BLEEDING
Rationale
Upper gastrointestinal bleeding is bleeding that occurred proximal to ligament of
Treitz, that can manifest as hematemesis and melena. These manifestation can be
caused by various etiology, which influenced their management.
A. Knowledge: Students should be able to define and describe:
1. the 2 kinds of upper GI bleeding; hematemesis which is vomiting of blood
or altered blood and melena which is altered blood per rectum.
2. the possible causes of upper GI bleeding, such as peptic ulcer,
gastropathy (alchol, nonsteroidal anti-inflammatory drugs, stress),
esophagitis, Mallory-Weiss tear, gastroesophageal varices.
3. the available diagnostic studies and their use according to the possible
causes of upper GI bleeding such as nasogastric aspirate, upper
endoscopy, upper GI barium radiography, peripheral blood count, stool
examination and fecal occult blood test.
4. the complications of upper GI bleeding such as hemodynamic changes,
shock, laboratory changes.
5. the alarm symptoms and signs such as age over 60, associated illnesses,
coagulopathy, immunosupression, presentation with shock, rebleeding,
onset of bleeding, variceal bleeding, endoscopic stigmata of recent
bleeding
6. the indiications for emergancy surgery such as uncontrolled or prolonged
bleeding, and severe rebleeding.
B. Skills: Students should demonstrate specific skills including:
1. History-taking skills:
Bye the end of the clerkship student should be able to obtain, document and
present an age-appropirate history, to distinguish the 2 kinds of upper GI
bleeding, including:
o hematemesis
o melena
and risk of upper GI bleeding including
o drugs (aspirin, NSAID)
o prior ulcer
o bleeding history
o family history
o features of cirrhosis or vasculitis
and the complications of upper GI bleeding including
o hemodynamic changes
o shock
o laboratory changes
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of upper GI bleeding including:
o vital signs
o other signs that show the risk of upper GI bleeding
 petechie, purpura, hematom, signs of chronic liver disease
and complications of disease
o hemodynamic changes
o shock portal hypertension
3. Differential diagnosis:
Student should be able to generate a prioritized differential diagnosis recognizing
specific history and physical exam finding that suggest a specific etiology.
4. Diagnostic and 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.
 peripheral blood count
 stool examination
 fecal occult blood test
 serum viral hepatitis markers (HBsAg, anti-HBc, anti-HBs, anti-HCV),
 albumin
 bleeding time (BT), clotting time (CT), prothrombin time (PT), activated
partial thromboplastin time (APTT), international normalized ratio (INR)
 abdominal ultrasound
 nasogastric aspirate
 upper endoscopy
 upper GI barium radiography
 students should be able to recommend when each of these test should be
ordered
5. Communication skills: Students should be able to:
 explain the results of the evaluation to the patient, taking into
consideration the patient’s knowledge about his/her condition
 communicate the diagnosis, treatment plan, and prognosis of the disease
to patients and their families, and consider the patient’s knowledge of
upper GI bleeding.
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
 provision of support and information to patient, and coordination of care
for work-up
 accessing and utilizing appropriate information systems and resources to
help delineate issues related to upper GI bleeding
 decide that all patients must be admittted to inhospital care
 fluid therapy & volume management
 medications need to be given such as
o blood transfusions
o vitamin K
o somatostatin
o propranolol
o isosorbid mono nitrate
o metochlopramide
o laxan
o antibiotics for cases of gastroesophageal varices bleeding
o H2 receptor antagonist or proton pump inhibitor
o antacid
o cytoprotector
7. Basic procedural skills: Skills that students should be able to perform:
 rectal examination
 nasogastric tube
C.
Attitudes and Professional Behaviors: Students should be able to:
 Student should be able to appreciate the importance of patient
preferences and compliances with management plan for those with upper
GI bleeding and its complication.
 Appreciate the importance of side effects of medications and their impact
on quality of life and compliance.
 Make appropriate referral to gastroenterology consultant for special case
of upper GI bleeding and its complications.
 Make appropriate referral to digestive surgery consultant for special case
of upper GI bleeding and its complications.
TRAINING PROBLEM: THYROID DISORDER
Rationale
Thyroid disorder in a common problem in endocrine patient beside diabetes mellitus.
Thyroid disorder comprise from autoimmune thyroid to malignant thyroid cancer.
Mastery of the approach to patient with throid disorder who could come with
hyperthyroid and hypothyroid is important to be general practioner because they
often are the first physician to see such patients.
Specific learning objectives
A. Knowledge: Students should be able to:
1. Describe and define definition of hyperthyroid and hypothyroid.
2. Describe the relative likehood of common causes of hyperthyroid and
hypothyroid
3. Describe the pathophysiology of common hyperthyroid and hypothyroid
disorder.
4. List the symptoms and signs of hyperthyroid and hypothyroid.
5. Describe and interpretate the simple laboratory related to hyperthyroid
and hypothyroid
6. Describe the key diagnosis criteria for the common cause of hyperthyroid
and hypothyroid, based on history, physical examination, and laboratory
testing.
7. Identify the indication of fine needle aspiration biopsy, and ultrasound and
thyroid scan to diagnose thyroid problems
8. Identify for first treatment planning for common cause of hyperthyroid
and hypothyroid.
9. Describe the emergency in thyroid disorder
10. Describe the education for thyroid patient.
B. Skills: students should demostrate specific skills including:
1. History-taking skills: student should be able to obtain, document, and
present an appropriate medical history that differentiates among etiologies
of disease including: to differentiate between hyperthyroid and
hypothyroid symptoms and signs, exacerbating and relieving symptoms
and signs, family history, medications, and surgery.
2. Physical exam skills: students should be able to perform physical exam
to establish the diagnosis of hyperthyroid and hypothyroid including:
- Demostrate the correct order and technique for examine the vital
signs, eyes, thyroid gland, lymphe node, heart, and extremities.
3. Differential diagnosis: student should be able to generate a list of the
most important and likely causes of hyperthyroid and hypothyroid,
recognizing specific history and physical exam findings that distinguish
between:
- Graves disease
- Plummer disease
- Hashimoto disease
- Thyroiditis
- Benign thyroid nodule
- Thyroid cancer
- Iodine deficiency
- Thyroid storm
4. Laboratory interpretation: Students should be able to recommend
when to order diagnostic and laboratory tests and be able to interpret
them, both prior and after initiating treatment based on the differential
diagnosis including consideration of test cost and performance
characteristics as well as patient preference laboratory and diagnostic
tests should include studies necessary to determine the cause of
hyperthyroid and hypothyroid.
5. Communication skills: Students should be able to:
- Explain the result of the evaluation to the patient, taking into
consideration the patient’s knowledge and his/her condition.
6. Basic and advance procedure skills: students should be able to:
- Fine needle aspiration biopsy of thyroid nodule
7. Management skills: Students should be able to develop appropriate
evaluation and treatment plan for patients, including:
- Selecting appropriate medical regimen for patients with graves
disease, iodine deficiency, benign thyroid nodule, emergency thyroid
storm, and thyroid storm.
- Determining when to prescribe medical therapy for patient with graves
disease, thyroid storm and iodine deficiency.
- Accesing and utilize appropriate information systems and resources to
help delineate issues related to common cause of hypothyroid and
hyperthyroid.
C. Attitudes and professional behavior: students should be able to:
- Recognize the importance of involving a surgical oncology, nuclear
medicine when facing thyroid cancer
- Recognize the importance of patient preferances when selecting
among treatment options.
TRAINING PROBLEM: TUBERCULOSIS
Rationale
Tuberculosis in a common problem in pulmonary field as we know tuberculosis is
endemic, common health problems in Indonesia.
Specific learning objectives
A. Knowledge: Students should be able to:
1. Describe and define definition lung and other sides tuberculosis
2. Describe the relative likehood of predilection of tuberculosis infection
3. Describe the pathophysiology of lung tuberculosis and others side
tuberculosis
4. List the symptoms and signs related to lung tuberculosis infection
5. Describe and interpretate the simple laboratory tuberculosis infections
6. Describe the key diagnosis criteria for lung tuberculosis and others side
tuberculosis
7. Identify for first treatment planning for tuberculosis infections
8. Describe the emergency in tuberculosis infections
9. Describe the education for tuberculosis patients.
B. Skills: students should demostrate specific skills including:
1. History-taking skills: student should be able to obtain, document, and
present an appropriate medical history that differentiates among risk
factors of disease including: main lung tuberculosis symptoms and signs,
exacerbating and relieving symptoms and signs, family history,
medications, and environment.
2. Physical exam skills: students should be able to perform physical exam
to establish the diagnosis of lung tuberculosis including:
- Demostrate the correct order and technique for examine the vital
signs, lymphe node, and lung.
3. Differential diagnosis: student should be able to generate a list of the
most important and likely causes of differential diagnose of lung
tuberculosis, recognizing specific history and physical exam findings that
distinguish between:
- Pneumonia
- Bronchiectasis
- Lung cancer
4. Laboratory interpretation: Students should be able to recommend
when to order diagnostic and laboratory tests and be able to interpret
them, both prior and after initiating treatment based on the differential
diagnosis including consideration of test cost and performance
characteristics as well as patient preference laboratory and diagnostic
tests should include studies necessary to determine complete blood count,
erythrocte sedimentation rate, sputum, chest x ray examination.
5. Communication skills: Students should be able to:
- Explain the result of the evaluation to the patient, taking into
consideration the patient’s knowledge and his/her condition.
6. Basic and advance procedure skills: students should be able to:
- Sputum staining, chest x ray intepretation, fine needle aspiration
biopsy of lymphe node.
7. Management skills: Students should be able to develop appropriate
evaluation and treatment plan for patients, including:
- Selecting appropriate medical regimen for patients with lung
tuberculosis.
- Determining when to prescribe medical therapy for patient with lung
tuberculosis.
- Accesing and utilize appropriate information systems and resources to
help delineate issues related to lung tuberculosis.
C. Attitudes and professional behavior: students should be able to:
- Recognize the importance of involving a surgeon
- Recognize the importance of patient preferances when selecting
among treatment options.
Training problem: Hepatitis
Rationale
Hepatitis is common problems in liver disease. Hepatitis could be caused by infection
which comprise from acute to chronic B and C hepatitis, drug induced, ischemia, and
other bacterial and parasite infections. Chronic hepatitis can be progress to became
hepatic cirrhosis and hepatocellular carcinoma.
Specific learning objectives
A. Knowledge: Students should be able to:
1. Describe and define acute and chronic hepatitis, drug induced and ischemia
hepatitis
2. Describe the relative likehood of differential diagnose of hepatitis
3. Describe the pathophysiology of common cause of hepatitis
4. List the symptoms and signs related to common cause of hepatitis
5. Describe and interpretate the simple laboratory of common cause of hepatitis
6. Describe the key diagnosis criteria for acute and chronic hepatitis, drug
induced hepatitis and ichemia hepatitis
7. Identify for first treatment planning for common cause of hepatitis
8. Describe the emergency in related to hepatitis
9. Describe the education for hepatitis patients.
B. Skills: students should demostrate specific skills including:
1. History-taking skills: student should be able to obtain, document, and
present an appropriate medical history that differentiates among risk factors
of disease including: hepatitis symptoms and signs, exacerbating and
relieving symptoms and signs, family history, medications, and environment.
2. Physical exam skills: students should be able to perform physical exam to
establish the diagnosis of hepatitis including:
- Demostrate the correct order and technique for examine the vital
signs, eye, lymphe node, and abdomen especially liver and spleen.
3. Differential diagnosis: student should be able to generate a list of the most
important and likely causes of differential diagnose of acute hepatitis, chronic
hepatitis, drug induced and ischemia hepatitis, recognizing specific history
and physical exam findings that distinguish between:
- Acute hepatitis
- Chronic hepatitis
- Drug induced hepatitis
- Ischemia hepatitis
- Bacterial and parasite infection of hepar
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
and after initiating treatment based on the differential diagnosis including
consideration of test cost and performance characteristics as well as patient
preference laboratory and diagnostic tests should include studies necessary to
determine complete blood count, erythrocte sedimentation rate, liver function
test, viral serology of hepatitis causes, and abdominal ultrasound
5. Communication skills: Students should be able to:
- Explain the result of the evaluation to the patient, taking into
consideration the patient’s knowledge and his/her condition.
6. Basic and advance procedure skills: students should be able to: none
7. Management skills: Students should be able to develop appropriate
evaluation and treatment plan for patients, including:
- Selecting appropriate medical regimen for patients with acute and
chronic heapatitis, and drug induced hepatitis
- Determining when to prescribe medical therapy for patient with
hepatitis.
- Accesing and utilize appropriate information systems and resources to
help delineate issues related to hepatitis.
8. Attitudes and proffesional behavior: students should be able to:
- Recognize the importance of involving hepatologist
- Recognize the importance of patient preferances when selecting
among treatment options.