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Emergency Medicine

I. Goals and Objectives:

The emergency medicine experience is designed to provide residents with a broad exposure to acute presentations of basic and complicated diseases in a wide variety of medical disciplines. Under direct supervision of an ER attending, residents are expected to develop the ability to diagnose, manage, and triage patients with these disease.  It is expected that residents at all levels take histories from and examine the patients independently, and then consult with the senior ER attendings.  It is expected that over the course of 3 years of Internal Medicine training, the house officer will be become familiar with the specific disease entities listed under the subspecialty disciplines sections of this curriculum. 

1)      Level based rotation goals and objectives:

PGY1/2/3

Patient Care: Take effective and efficient histories and physicals; formulate differential diagnoses; recognize urgent conditions; recognize acuity levels of patients; triage within the acute care setting; understand the indications, contraindications and risks of common procedures.

Medical Knowledge:  Use literature and reference sources to increase knowledge base; demonstrate knowledge in the areas of underlying pathophysiology and the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients. 

Professionalism:  Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients, staff, housestaff from other service areas and supervising faculty; understand limitations and ask supervisors for help when indicated. 

Interpersonal Skills: Write understandable and legible notes; more fully develop ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team. 

Practice Based Learning and Improvement:  Understand limitation of knowledge and use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of patients under your care and alter practice patterns to improve outcomes in the future. 

Systems Based Practice:  Advocate for patients; develop an understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients.

  

II. DISCIPLINES COVERED DURING ROTATION

1)      Allergy/Immunology

A)    Goals and objectives

a)      Principles, physiology and basic science: Develop a basic understanding of the immune system

b)      Practice skills unique to Allergy

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation:  skin testing, desensitization

iii)                Preventive care: Avoidance of allergens

iv)                Patient education: Avoidance of allergens, availability of medications

v)                  Attitudes/values: Understand the psychosocial issues involved in patients with chronic allergic/immunologic diseases

c)      Approach to presenting complaints/problems

i)                    Itching
ii)                  Hives
iii)                Allergic rash
iv)                Upper respiratory complaints
v)                  Anaphylaxis

d)     Specific diagnoses in Allergy

i)                    Hives
ii)                  Anaphylaxis

e)      Emergencies

i)                    Anaphylaxis

ii)                  Exfoliation

f)       Treatment modalities

i)                    Medication (antihistamines, steroids)

ii)                  Desensitization

g)      Technical skills:

            i)          Skin testing (familiarity)

 2)      Cardiology

A)    Goals and objectives: (supplemented by Cardiology rotation)

a)      Principles, physiology and basic science: Understand the physiology of the heart as a pump, conduction system and the physiology of hypertension

b)      Practice skills unique to Cardiology:

i)                    History and physical exam

ii)                  Specific tests and procedures: use and interpretation: EKG, catheterization/angioplasty/stent placement, echocardiography, nuclear studies, tilt table testing, EP studies, holter monitor

iii)                Preventive care: risk factor modification

iv)                Patient education: risk factor modification, cardiac rehabilitation, diet, recognition of cardiac symptoms

v)                  Attitudes/values: Understand the impact of acute  or chronic cardiac disease on the patient.

c)      Approach to presenting complaints/problems:

i)                    Dyspnea
ii)                  Chest pain
iii)                Palpitations
iv)                Edema
v)                  Claudication
vi)                Syncope

d)     Specific diagnoses in Cardiology:

i)                    CAD: ischemia/myocardial infarction
ii)                  Hypertension
iii)                Valvular disease
iv)                Arrhythmias
v)                  CHF
vi)                Pericardial disease
vii)              Hyperlipidemia

e)      Emergencies:

i)                    Myocardial infarction/cardiogenic shock

ii)                  Congestive heart failure/pulmonary edema

iii)                Malignant hypertension

iv)                Tamponade

v)                  Malignant arrhythmias

f)       Treatment modalities:

i)                    Pharmacology
ii)                  Pacemakers/Cardioversion/ICDs
iii)                Pericardiocentesis
iv)                CPR/ACLS
v)                  Stents/bypass grafting
vi)                Valvular surgery

g)      Technical skills:

            i)          Central venous catheters

            ii)         EKG interpretation 

3)      Dermatology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand basic skin physiology

b)      Practice skills unique to Dermatology:

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: skin biopsy, KOH prep, Wood’s light, Tzanck prep

iii)                Preventive care: sunscreen, sun avoidance, routine skin examinations, diet

iv)                Patient education: topical ointments, sun avoidance, yearly skin examinations

v)                  Attitudes/values: Understand the psychosocial burden carried by patients with serious skin diseases

c)      Approach to presenting complaints/problems:

i)                    Rash

ii)                  Ulcers

iii)                Itching

iv)                Other skin lesions (bullae)

d)     Specific diagnoses in Dermatology:

i)                    Eczematous dermatitis
ii)                  Drug eruptions
iii)                Psoriasis
iv)                Disorders of sebaceous glands
v)                  Disorders of hair
vi)                Disorders of dermis and dermal-epidermal interface
vii)              Bullous diseases
viii)            Syndromes involving blood vessels
ix)                SLE
x)                  Metabolic and Heritable Disorders
xi)                Infections (bacterial, fungal, viral)
xii)              Syphilis
xiii)            Insect bites and infestations
xiv)            Neoplasms (benign/malignant)

e)      Emergencies

i)                    Exfoliation

ii)                  Burns

f)       Technical skills:      Biopsy

 

4)      Endocrinology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand the physiology of the thyroid gland, testes and ovaries, adrenals, pituitary, parathyroid, pancreas

b)      Practice skills unique to Endocrinology:

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: hormonal assays, thyroid scanning/imaging, osteoporosis imaging

iii)                Preventive care: exercise, diet

iv)                Patient education: exercise, diet, replacement medications, foot care (dm), BS management (dm)

       v)        Attitudes/values: Understand the issues confronted by patients with endocrinologic diseases

c)      Approach to presenting complaints/problems:

i)                    Weight changes
ii)                  Thyroid nodules, goiter
iii)                Hirsuitism
iv)                Amenorrhea
v)                  Galactorrhea
vi)                Incidental adrenal mass
vii)              Abn Calcium homeostasis
viii)            Symptoms of abnormal blood sugar
ix)                Diabetic foot problems
x)                  Impotence

d)     Specific diagnoses in Endocrinology:

i)                    Differential diagnosis of hyperthyroidism and hypothyroidism; euthyroid sick syndrome
ii)                  Thyroid cancer
iii)                Ovarian functional abnormalities
iv)                Cushings
v)                  Hyperaldosteronism
vi)                Addison’s disease
vii)              Pituitary disease (adenomas)
viii)            Diabetes mellitus
ix)                Diabetes Insipidus
x)                  SIADH/Hypernatremia
xi)                Hyperparathyroidism
xii)              Pagets’ disease
xiii)            Osteoporosis
xiv)            Multiple Endocrine Neoplasias
xv)              Pheochromocytoma

e)      Emergencies:
i)                    Diabetic Ketoacidosis
ii)                  Hyperosmolality/Hypoosmolality (hyponatremia)
iii)                Hyper/Hypocalcemia
iv)                Myxedema coma
v)                  Addisonian crisis
vi)                Hypoglycemia

f)       Treatment modalities:
i)                    Radioactive iodine
ii)                  Medications for hyperthyroidism/hypothyroidism
iii)                Treatment for diabetes mellitus
g)      Technical skills:
i)          Fingerstick glucose monitoring

 

5)      Gastroenterology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand GI anatomy, physiology of digestion, neurohumoral interactions, liver anatomy and physiology

b)      Practice skills unique to Gastroenterology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: liver tests, upper and lower GI endoscopy, capsule endoscopy, guiaic testing, liver/spleen scanning, CT/MRI, UGI and small bowel series, barium enema, ERCP/ultrasonography, GI motility studies, stool examinations, bleeding scan, oral cholecystogram, TIPS procedure, liver biopsy

iii)                Preventive care: alcohol, typlenol, diet, colon cancer screening, hepatitis immunization

iv)                Patient education: alcohol, smoking, diet, fiber, alcohol rehabilitation

v)                  Attitudes/values: Understand the burden carried by patients with GI and liver disease and their families, understand the psychosocial dynamics surrounding alchoholism

c)      Approach to presenting complaints/problems:

i)                    Abdominal pain
ii)                  Diarrhea/constipation
iii)                Appetite/weight changes
iv)                Jaundice
v)                  Nausea and vomiting
vi)                Perianal discomfort
vii)              Dysphagia/non-cardiac chest pain
viii)            Abnormal liver tests
ix)                Post exposure hepatitis prophylaxis
x)                  Malabsorption
xi)                Liver failure
xii)              Iron deficiency anemia
xiii)            Pharmacology and side effects of GI mediciation
xiv)            Obesity
xv)              Malnutrition
xvi)            Hematemesis, rectal bleeding, melena, GI bleeding

d)     Specific diagnoses in Gastroenterology:

i)                    Esophagitis/Esophageal strictures/reflux, spasm, carcinoma
ii)                  Achalasia
iii)                Ulcer disease
iv)                Gastric cancer/gastrinoma
v)                  Pancreatic insufficiency, pancreatitis, pancreatic carcinoma
vi)                Carcinoid syndrome
vii)              Irritable bowel syndrome
viii)            Colitis: ulcerative, Crohn’s, ischemic, infectious
ix)                Cholelithiasis, cholecystitis, cholangitis
x)                  Hepatitis: viral, drug induced
xi)                Alcoholic liver disease
xii)              Alpha I antitrypsin deficiency
xiii)            Hemochromatosis, hemosiderosis
xiv)            Primary biliary cirrhosis
xv)              Cirrhosis
xvi)            Esophageal varices
xvii)          Divericulosis/diverticulitis
xviii)        Hepatorenal syndrome
xix)            Sprue
xx)              Whipple’s disease
xxi)            AIDS and the GI tract
xxii)          Appendicitis
xxiii)        Colonic polyps and cancer
xxiv)        Peritonitis

e)      Emergencies:

i)                    GI bleeding
ii)                  Acute hepatic failure
iii)                Acute cholangitis, acute choecystitis
iv)                Severe pancreatitis
v)                  Surgical emergencies: bowel performation, acute abdomen

f)       Treatment modalities:

i)                    Drug therapy
ii)                  Enteral alimentation, parenteral alimentation (TPN)
iii)                TIPS
iv)                Esophageal dilatation, dilatation of webs, strictures, rings,
v)                  Schlerotherapy/banding of varices
vi)                ERCP with gall stone removal, papillotomy
vii)              Endoscopic treatment of bleeding lesions

g)      Technical skills:

            i)          Nasogastric tube placement
            ii)         Paracentesis

 

6)      Geriatrics

A)    Goals and objectives (supplemented by Geriatrics rotation)

a)      Principles, physiology and basic science: Understand the physiology of aging, understand the hazards of hospitalization in older adults, understand home/institutional safety issues for older adults

b)      Practice skills unique to Geriatrics

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: psychosocial testing

iii)                Preventive care: falls, decubiti, diet, advanced directives

iv)                Patient and caregiver education: social interaction, falls, decubiti, diet, advanced directives

v)                  Attitudes/values: Understand the difficulties that some individuals face with age, respect patient dignity

c)      Approach to presenting complaints/problems:

i)                    Confusion and other changes in behavior
ii)                  Incontinence
iii)                Anemia
iv)                Weight loss
v)                  Changes in appetite
vi)                Bruises/fractures
vii)              Physical limitations: inability to ambulate, transfer etc
viii)            Elder care
ix)                Osteoporosis

d)     Specific diagnoses in Geriatrics:

i)                    Dementia
ii)                  Delerium
iii)                Incontinence
iv)                Parkinson’s disease
v)                  Anemia
vi)                Cancer
vii)              Depression
viii)            “Polypharmacy”
ix)                Elder abuse

e)      Emergencies:

i)                    Elder abuse

ii)                  Change in mental status

f)       Treatment modalities:

i)                    Medications (including anticoagulation in the elderly)

ii)                  Institution of supporting care (home care, day care, family meetings)

iii)                Surgery

iv)                Age appropriate health care maintenance

g)      Technical skills:

i)         Advanced directives
ii)        Skill with family meetings
iii)      Work with bioethics team
iv)       Work with health care team for disposition  

 

7)      Hematology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand the basic pathways involved in hematopoiesis, hemostasis and the immune system.

b)      Practice skills unique to Hematology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: CBC, peripheral smear, reticulocyte count, Fe studies, B12 studies, tests assessing hemolysis, Hb electrophoresis,  SPEP/UPEP, coagulation tests, antibodies

iii)                Preventive care: nutritional requirements for hematopoiesis, monitoring patients on anticoagulation

iv)                Patient education: living with chronic hematologic diseases (ex SS), medications, signs of bleeding, risks of transfusions

v)                  Attitudes/values: Understand the burden on patients living with chronic pain (ex SS)

c)      Approach to presenting complaints/problems:

i)                    Pallor, orthostasis

ii)                  Recurrent infections

iii)                Bleeding

iv)                Thrombosis

v)                  Lymphadenopathy

vi)                Splenomegaly

d)     Specific diagnoses in Hematology:

i)                    Diseases of RBC: Anemias: aplastic, Fe deficiency, B12 deficiency, chronic disease, hemolytic, sickle cell; Hemoglobinopathies

ii)                  Diseases of WBC: Neutropenia, Leukocytosis, Malignancies (leukemia, lymphoma, multiple myeloma)

iii)                Diseases of Platelets: thrombocytopenia, thrombocytosis

iv)                Hemostatic disorders: ex. Hemophilias, von Villebrand disease, circulating anticoagulants, ITP, DIC/TTP/HUS, hypercoagulable states

v)                  Hematologic complications of systemic conditions: ex: AIDS, connective tissue diseases, alcohol, organ failure (ex renal), sepsis, pregnancy

vi)                Hematologic complications of medical therapies: ex drug toxicities

e)      Emergencies:

i)                    Pancytopenia
ii)                  Severe anemia
iii)                Blast crisis/leukostasis
iv)                Superior vena cava syndrome
v)                  Hyperviscosity
vi)                Severe thrombocytopenia
vii)              DIC/HUS/TTP
viii)            Bleeding
ix)                Transfusion reactions

f)       Treatment modalities:

i)                    Anticoagulation
ii)                  Use of blood components
iii)                Use of growth factors
iv)                Selected antineoplastic agents
v)                  Pheresis
vi)                Other: ex: prednisone, gamma globulin, DDAVP

g)      Technical skills:

            i)         Peripheral blood smear interpretation
            ii)        Therapeutic phlebotomy
            iii)       (Bone marrow biopsy/aspiration)

 

8)      Infectious Diseases/HIV

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand microbiological virulence factors, host defenses and the principles of antibiotic therapy

b)      Practice skills unique to I.D.

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: gram stain/acid fast stain, tzanck prep, nuclear medicine scans, antibotic sensitivity testing, institutional antibiotic restriction, nosocomial infections and infection control, use of blood cultures, skin testing

iii)                Preventive care: immunizations, TB screening, rheumatic fever prophylaxis, endocarditis prophylaxis, travel medicine, surgical wound prophylaxis, nosocomial infections

iv)                Patient education: value of immunizations, risk from highly contagious diseases, HIV risk reduction

v)                  Attitudes/values: Understand the needs of patients and families with chronic diseases (ex. HIV)

c)      Approach to presenting complaints/problems:

i)                    Fever/FUO
ii)                  Respiratory infections
iii)                Urinary infections
iv)                Intra abdominal infections
v)                  Diarrheas
vi)                Cardiovascular infections
vii)              CNS infections
viii)            Skin/soft tissue infections
ix)                Bone and joint infections
x)                  Sexually transmitted diseases
xi)                Nosocomial infections
xii)              Infections in compromised hosts
xiii)            Infected prostheses
xiv)            Postoperative and post traumatic infections
xv)              Travel medicine
xvi)            Antibiotics: allergies and reactions
xvii)          Antibiotic/ Antretroviral resistance
xviii)        Sepsis syndromes

d)     Specific diagnoses in I.D.:

i)                    HIV; HIV drug resistance
ii)                  Pseudomembranous colitis
iii)                Hepatitis (viral)
iv)                Herpes infections
v)                  Atypical and typical pneumonias
vi)                Tick born diseases
vii)              Toxic shock syndrome
viii)            Sexually transmitted diseases (GC, syphilis, chlamydia)
ix)                Vibrio cholerae
x)                  Listeriosis
xi)                Meningitis (bacterial and viral)
xii)              Encephalitis
xiii)            Fungal diseases
xiv)            Cat scratch disease and bacillary angiomatosis
xv)              TB and other mycobacterial diseases
xvi)            Amebiasis
xvii)          Malaria
xviii)        Infectious diarrheas

e)      Emergencies:

i)                    Septic shock/ toxic shock

ii)                  Overwhelming bacterial or fungal infection

iii)                Meningitis

f)       Treatment modalities:

i)                    Antibiotics; Antiretrovirals; Antivirals

ii)                  Surgery

iii)                Immunotherapy

iv)                Hematopoietic colony stimulating factors

v)                  Anti-toxins

g)      Technical skills:

            i)          Gram stain and AFB stain

            ii)         Lumbar puncture

            iii)        Blood cultures

 

9)      Nephrology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand basic glomerular and tubular function, electrolyte and water handling in the kidney and acid-base physiology

b)      Practice skills unique to Nephrology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: urinanalysis (with Uosm), sonography, CT/MRI, nuclear scans, renal biopsy

iii)                Preventive care: microalbuminuria in dm, monitoring of renal lab tests

iv)                Patient education: diet, adherence to antihypertension medications, symptoms of uremia, pre-dialysis counseling

v)                  Attitudes/values: understand the psychosocial issues surrounding chronic illness, dialysis and withdrawal of dialysis

c)      Approach to presenting complaints/problems:

i)                    Dysuria
ii)                  Hematuria
iii)                Edema anasarca
iv)                Flank pain
v)                  Changes in urine volume
vi)                Obstructive uropathy
vii)              Proteinuria/nephrotic syndrome
viii)            Glomerulonephritis
ix)                Use of nephrotoxic agents
x)                  Dosage modification in renal failure
xi)                Hypertension

d)     Specific diagnoses in Nephrology:

i)                    Infections of the kidney
ii)                  Acute renal failure
iii)                Chronic renal failure (including dialysis and transplantation)
iv)                Hereditary kidney diseases (ex Polycystic)
v)                  Electrolyte abnormalities (ex. Hypo/hypernatremia (SIADH, DI), hypo/hypercalcemia, hypo/hyperphosphatemia, hypo/hypermagnesemia, hypo/hyperkalemia)
vi)                Acid-base abnormalities
vii)              Renal complications of systemic diseases
viii)            Nephrolithiasis
ix)                Hypertension
x)                  Renal Tumors
xi)                Glomerular Diseases (nephrosis/nephritis)
xii)              Kidney diseases in pregnancy

e)      Emergencies:

i)                    Acute hyperkalemia
ii)                  Anuria
iii)                Severe acidosis/alkalosis
iv)                Uremia (indications for dialysis)
v)                  Hypertensive crisis

f)       Treatment modalities:

i)                    Medications (ACEI, ARB, BP medications)

ii)                  De-obstruction (stents, nephrostomy, lithotripsy)

iii)                Erythropoietin

g)      Technical skills:

            i)          Familiarity with renal biopsy

                     ii)         Urinalysis

                     iii)        Fundoscopic exam

 

10)  Neurology

A)    Goals and objectives (supplemented by Neurology rotation)

a)      Principles, physiology and basic science: Understand basic neurological pathways and how that translates into neurological function

b)      Practice skills unique to Neurology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: CT/MRI, EEG, LP

iii)                Preventive care: understand importance of BP control as it relates to CVA events

iv)                Patient education: BP control, importance of medication adherence, signs and symptoms of cerebral events

v)                  Attitudes/values: Understand the psychosocial issues in patients with chronic neurologic diseases

c)      Approach to presenting complaints/problems:

i)                    Change in mental status

ii)                  Seizures/Twitching

iii)                Focal weakness

iv)                Headache

v)                  Neck stiffness

d)     Specific diagnoses in Neurology:

i)                    Coma
ii)                  Headache
iii)                Seizures/status epilepticus
iv)                Disorders of gait and coordination
v)                  Disorders of mentation and language
vi)                Acute intracranial catastrophes
vii)              Extrapyramidal disorders
viii)            Demyelinating diseases
ix)                Central nervous system infections
x)                  Neurologic complications of AIDS
xi)                Psychogenic disorders with neurologic presentation
xii)              Myasthenia gravis, Guillain-Barre and other neurologic diseases with respiratory presentation
xiii)            CVA/TIA
xiv)            Indications for anticoagulation

e)      Emergencies:

i)                    Acute change in mental status

ii)                  Status epilepticus

iii)                Meningitis

iv)                Increased intracranial pressure

f)       Treatment modalities:

i)                    Medications

ii)                  Anticoagulation

iii)                Physical and occupational therapy

g)      Technical skills:

    i)         Lumbar puncture

    ii)        CT/MRI

    iii)       Neurological examination

 

11)  Oncology

A)    Goals and objectives (supplemented by Oncology rotation)

a)      Principles, physiology and basic science: Understand the genesis of malignancy, behavior of malignant cells and unique characteristic of various tumors. Understand chemotherapy

b)      Practice skills unique to Oncology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: biopsies, imaging modalities, tumor markers, cytology

iii)                Preventive care: environmental exposure, smoking cessation, alcohol cessation, diet, screening, genetic counseling

iv)                Patient education: appropriate cancer screening, self examination, diet, sunscreen/sun exposure, smoking cessation

v)                  Attitudes/values: Understand the psychosocial issues in patients with cancer, weigh the risks and benefits of therapy, understand the physical symptoms and signs of chemotherapy, advanced directives and DNR

c)      Approach to presenting complaints/problems:

i)                    Adenopathy
ii)                  Mass/nodule
iii)                Cancer of unknown primary
iv)                Acute neurologic events
v)                  Superior vena cava obstruction
vi)                Electrolyte abnormalities (hypercalcemia, hyponatremia)
vii)              Pericardial tamponade
viii)            Infectious and hematologic complications of therapy
ix)                Weight loss
x)                  Hemoptysis and airway obstruction
xi)                Nausea and vomiting

d)     Specific diagnoses in Oncology

i)                    Lung cancer
ii)                  Head and Neck cancer
iii)                Breast cancer
iv)                Esophageal cancer
v)                  Gastric cancer
vi)                Pancreatic cancer
vii)              Hepatocellular cancer
viii)            Colorectal cancer
ix)                Prostate cancer
x)                  Bladder cancer
xi)                Renal cancer
xii)              Testicular cancer
xiii)            Uterine cancer
xiv)            Cervical cancer
xv)              Ovarian cancer
xvi)            Lymphoma (Hodgkins/non-Hodgkins)
xvii)          Leukemias
xviii)        Osteosarcoma
xix)            Brain tumors
xx)              Skin cancer
xxi)            Cancer related to HIV/post transplant

e)      Emergencies:

i)                   Superior vena cava syndrome
ii)                  Spinal cord compression
iii)                Brain metastases with increased intracranial pressure
iv)                Hypercalcemia
v)                  Tumor lysis syndrome
vi)                Pericardial tamponade
vii)              Infections
viii)            Cytopenias
ix)                GI obstruction
x)                  Obstructive uropathy
xi)                Hemolytic uremic syndrome

f)   Treatment modalities:

xii)              Chemotherapy

xiii)            Radiation therapy

xiv)            Molecular targeted therapies

xv)              Surgery

xvi)            Antiemetic therapy

xvii)          Pain management

xviii)        Nutritional support

xix)            Hospice care

f)       Technical skills:

            i)          Bone marrow aspirate/biopsy (familiarity)

 

12)  Pulmonary

A)    Goals and objectives (supplemented by Pulmonary rotation)

a)      Principles, physiology and basic science: Understand the physiology of respiration, gas exchange, oxygen delivery, lung defense mechanisms and anatomy of the lungs

b)      Practice skills unique to Pulmonary

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: spirometry/lung volumes/diffusion capacity, CXR/CT, sputum gram stain/AFB, PPD, ABG, V/Q scan, angiography, venography, thoracentesis, bronchoscopy, pleural biopsy, sleep studies, exercise testing

iii)                Preventive care: smoking cessation, industrial exposure, environmental exposure, TB screening and prevention, DVT prophylaxis

iv)                Patient education: smoking cessation, breathing exercises, asthma education

v)                  Attitudes/values: Undertand the issues faced by individuals with chronic pulmonary diseases

c)      Approach to presenting complaints/problems:

i)                    Acute respiratory failure
ii)                  Dyspnea
iii)                Cough
iv)                Hemoptysis
v)                  Chest pain
vi)                Hypoxia
vii)              Hypercapnia
viii)            Somnolence/sleep disturbance
ix)                Lung nodule
x)                  Pleural effusion
xi)                Wheezing
xii)              Anticoagulation therapy
xiii)            Thoracentesis/Chest tube insertion

d)     Specific diagnoses in Pulmonary:

i)                    Lung cancer
ii)                  Pneumonias and other infections
iii)                Alpha I antitrypsin deficiency
iv)                Cystic fibrosis
v)                  Vasculitis
vi)                Sacrcoidosis
vii)              Drug toxicity
viii)            Pneumoconioses
ix)                ARDS
x)                  Pneumothorax
xi)                Empyema
xii)              COPD
xiii)            AIDS related pulmonary diseases

e)      Emergencies:

i)                    Acute respiratory failure

ii)                  Tension pneumothorax

iii)                Lung collapse

iv)                Hemoptysis

v)                  Upper airway obstruction

vi)                Acute pulmonary embolus

f)       Treatment modalities:

i)                    Oxygen therapy

ii)                  Bronchodilator therapy

iii)                Antibiotic therapy

iv)                Mechanical ventilation

v)                  Anticoagulation/ IVC filter/thrombectomy procedures

vi)                Cancer chemotherapy

g)      Technical skills:

            i)          ABG

            ii)         Thoracentesis

            iii)        Intubation (familiarity)

            iv)        Skin testing

            v)         Mechanical ventilation

 

13)  Rheumatology

A)    Goals and objectives

a)      Principles, physiology and basic science: Understand the role of immunologic mechanisms in rheumatic diseases, understand the anatomy and physiology of joints and tendons

b)      Practice skills unique to Rheumatology

i)                    History and physical examination

ii)                  Specific tests and procedures: use and interpretation: arthrocentesis, synovial biopsy, arthroscopy, autoantibodies, serologic tests, MRI/CT/US, synovial fluid analysis

iii)                Preventive care: diet, osteoporosis prophylaxis, vaccines/infection prophylaxis

iv)                Patient education: coping with chronic disease and chronic pain, understand cytoxic drugs, joint protection, exercise

v)                  Attitudes/values: Understand the impact of chronic disease and chronic pain on patients

c)      Approach to presenting complaints/problems:

i)                    Monoarticular arthritis
ii)                  Polyarticular arthritis
iii)                Low back pain
iv)                Neck pain
v)                  Diffuse muscle pain
vi)                Raynaud’s phenomenon
vii)              Sicca syndrome
viii)            Uveitis
ix)                Breast implants
x)                  Rash/vasculitis
xi)                Glomerulonephritis associated with systemic disease
xii)              Entrapment syndromes

d)     Specific diagnoses in Rheumatology:

i)                    RA/JRA
ii)                  SLE
iii)                Antiphospholipid syndrome
iv)                Systemic schlerosis
v)                  MCTD
vi)                Sjogren’s syndrome
vii)              Myositis
viii)            Systemic necrotizing vasculitis
ix)                Cryoglobulinemia
x)                  Polymyalgia rheumatica
xi)                Temporal Arteritis
xii)              Polychondritis
xiii)            Ankylosing spondylosis/Reiter’s syndrome
xiv)            Psoriatic arthritis
xv)              Acute rheumatic fever
xvi)            Osteoarthritis
xvii)          Infectious arthritis
xviii)        Lyme
xix)            Sarcoidosis
xx)              Gout/CPPD
xxi)            Fibromyalgia
xxii)          HIV associated arthropathy
xxiii)        Osteonecrosis
xxiv)        Osteoporosis
xxv)          Reflex sympathetic dystrophy
xxvi)        Radiculopathy
xxvii)      Spinal stenosis

e)      Emergencies:

i)                    Septic arthritis

ii)                  Lupus crisis

iii)                Scleroderma renal crisis

iv)                Cervical spine subluxation

v)                  CNS vasculitis

vi)                Mesenteric vasculitis

vii)              Thrombosis

f)       Treatment modalities:


i)                    NSAID (including COX-2 inhibitors)
ii)                  Antimalarials
iii)                Penicillamine, Gold
iv)                Cytotoxic drugs (AZA, Methotrexate, chlorambucil, leflunimide, CTX)
v)                  Cyclosporin
vi)                Sulfasalazine
vii)              IL-1 inhibitors
viii)            TNF blockade
ix)                Steroids
x)                  IV IG
xi)                Plasmapheresis
xii)              Intraarticular therapy
xiii)            Physical therapy
xiv)            Synovial surgery
xv)              Joint replacement

g)      Technical skills:

            i)          Arthrocentesis

             i)         Punch skin biopsy

 

14)  Orthopedics

 A) Goals and Objectives

a)      Principles, physiology, and basic science:

b)      Practice skills unique to Orthopedics

i)                    History and physical examination

ii)                  Specific tests and procedures: autoantibodies, serologic tests, MRI/CT, synovial fluid analysis

iii)                Preventive care: diet, osteoporosis prophylaxis

iv)                Patient education: coping with chronic disease and chronic pain, joint protection, ROM and muscle strengthening exercises

v)                  Attitudes/values: Understand the impact of chronic disease and chronic pain on patients

c)      Approach to presenting complaints/problems:

i)                    Monoarticular arthritis
ii)                  Polyarticular arthritis
iii)                Low back pain
iv)                Neck Pain
v)                  Foot/Ankle pain/trauma
vi)                Fractures of the long bones
vii)              Joint swelling/effusions
viii)            Shoulder injuries
ix)                Knee injuries

d)     Specific diagnoses in Orthopedics:

i)                    Septic arthritis
ii)                  Herniated disc disease
iii)                Fractures (arm, leg, ankle/foot)
iv)                Ankle sprains
v)                  tendonitis
vi)                Entrapment syndromes
vii)              Rotator cuff tear
viii)            Shoulder dislocation
ix)                Meniscal tears of knee
x)                  Ligament tears of knee
xi)                Osteoarthritis
xii)              Rheumatiod arthiritis

e)      Emergencies:

i)                    Septic arthritis

ii)                  Cervical spine subluxation

iii)                Acute fractures (humerus, femur, tibia/fibula, ankle/foot)

f)       Treatment modalities:

i)                    Joint aspiration

ii)                  Setting of fracture

iii)                NSAIDS

iv)                Steriods

v)                  Joint replacement

vi)                Ace bandage

vii)              Tendon injections

g)      Technical skills:

i)                    Arthrocentesis

 

15)  General Surgery

A)  Goals and Objectives

a)      Principles, physiology, and basic science:

b)      Practice skills unique to General Surgery

i)                    History and physical examination

ii)                  Specific tests and procedures: CT Scan, ultrasound, MRI interpretation

iii)                Preventive care: diet

iv)                Patient education:

v)                  Attitudes/values:  understanding patients’ psychosocial stress related to undergoing operative procedures

c)      Approach to presenting complaints/problems:

i)                    Abdominal pain

ii)                  Rectal bleeding

iii)                Hematemesis

iv)                Nausea and Vomiting

v)                  Nonhealing wounds

vi)                Post-op infections

vii)              Skin infection

d)     Specific diagnoses in General Surgery:

i)                    Cholecystitis

ii)                  Cholanigitis

iii)                Appendicitis

iv)                Diverticulitis

v)                  Pancreatitis

vi)                Perforated intestine

vii)              Hemorrhoids

viii)            Colonic AVM

ix)                Colitis

x)                  Wound infection

xi)                Post-op pneumonia, etc.

xii)              Cellulits

xiii)            Skin abscess

e)      Emergencies:

i)                    Cholecystitis

ii)                  Cholangitis

iii)                Appendicitis

iv)                Perforated intestine

v)                  Colonic AVM

f)       Treatment modalities:

i)                    Cholecystectomy

ii)                  Appendectomy

iii)                Hemicolectomy

iv)                Hemorroidectomy

v)                  Supportive care: bowel rest/NPO

vi)                IV antibiotics

vii)              Wound care

viii)            Incision and drainage of abscess

g)      Technical skills:

i)                    Incision and drainage of abscess

ii)                  Wound care/dressing changes

 

16)  Urology

A)  Goals and Objectives

a)      Principles, physiology, and basic science:

b)      Practice skills unique to Urology

i)                    History and physical examination

ii)                  Specific tests and procedures: urine dipstick, CT Scan, ultrasound, and MRI interpretation

iii)                Preventive care:

iv)                Patient education:

v)                  Attitudes/values:  understanding patients’ psychosocial stress related to undergoing operative procedures

c)      Approach to presenting complaints/problems:

i)                    Dysuria

ii)                  Renal colic

iii)                Incontinence

iv)                Hematuria

v)                  Pelvic pain

vi)                Erectile dysfunction

vii)              Urinary hesitancy or frequency

d)     Specific diagnoses in General Surgery:

i)                    Urinary tract infection

ii)                  Pyelonephritis

iii)                Nephrolithiais

iv)                Stress incontinence

v)                  Overflow incontinence

vi)                Urinary obstruction

vii)              Erectile dysfunction

viii)            Benign prostatic hypertrophy

ix)                Prostate cancer

x)                  Bladder cancer

xi)                Renal tumors

e)      Emergencies:

i)                    Urinary obstruction

f)       Treatment modalities:

i)                    Surgical resection of tumors

ii)                  Alpha blockers

iii)                Erectile dysfunction medication classes

iv)                Lithotripsy

v)                  Prostatectomy

vi)                Antibiotics

vii)              Kegel exercises

viii)            Foley catheter insertion

g)      Technical skills:

i)                    Urine microscopic analysis

ii)                  Foley catheter insertion

iii)                Pelvic exams

 

17)  Gynecology

A)  Goals and Objectives

a)      Principles, physiology, and basic science:

b)      Practice skills unique to Gynecology

i)                    History and physical examination: performing pelvic exams and collecting specimens (e.g. PAP smear, endocervical discharges)

ii)                  Specific tests and procedures: wet mounts

iii)                Preventive care: safer sex counsel, family planning, contraception care

iv)                Patient education: safer sex counsel, contraception care

v)                  Attitudes/values:  Understanding the impact of pregnancy or termination of pregnancy on patients’ psychological health.

c)      Approach to presenting complaints/problems:

i)                    Pelvic pain

ii)                  Vaginal discharge

iii)                Dysuria

d)     Specific diagnoses in Gynecology:

i)                    Pelvic Inflammatory Disease

ii)                  Pregnancy

iii)                Ovarian Cyst

iv)                Ovarian Tortion

v)                  Urethritis

vi)                Urinary Tract Infection

vii)              Uterine Fibriods

viii)            Tubal Pregnancy

e)      Emergencies:

i)                    Ovarian Tortion

ii)                  Tubal Pregnancy

f)       Treatment modalities:

i)                    Emergency Contraction

ii)                  D & C

g)      Technical skills:

i)                    Performing pelvic exams

ii)                  Examining wet mounts, KOH Preps

 

18)  Toxicology

A)    Goals and objectives: understanding the prevention, diagnosis and management of  alcohol, heroin, cocaine, and other toxins overdose and withdrawal in patients

a)      principles, physiology and basic science

b)      practice skills unique to Toxicology

i)                    specific tests and procedures: use and interpretation

ii)                  preventive care: understand referral sources for detox

iii)                patient education:  withdrawal symptom education

            iv)       attitudes/values:  understand the interplay between substance abuse and psychiatric illness. Develop empathy skills for caring for patients with these illnesses.

c)      approach to presenting complaints/problems:

i)                    Acute ingestion

ii)                  Suicidality

iii)                Acute withdrawal symptoms

iv)                Chronic dependence

d)     specific diagnoses in Toxicology

i)                    Alcohol overdose

ii)                  Alcohol withdrawal

iii)                Heroin overdose

iv)                Heroin withdrawal

v)                  Acetaminophen overdose

vi)                Chronic substance use

e)      emergencies:

i)                    Acute ingestion

ii)                  Acute withdrawal

f)       treatment modalities:

i)                    Charcoal administration

ii)                  Narcan administration

iii)                Psychiatric care

g)      technical skills

i)                    Placing an NGT tube

 

     II.  ROUNDS AND CONFERENCES

1)      Rounds:  A senior ER faculty is assigned to oversee each houseofficer.  After independently taking a history and performing a physical exam on an assigned patient, the resident will present the case to the attending.  The attending will confirm the findings with the patient and together they will formulate a triage decision and acute treatment plan.  Although the ER attending oversees many housestaff during the same time period, this “rounding” takes place one-on-one.

         

     

III. METHODS OF TEACHING COMPETENCIES AND OF COMPETENCY ASSESSMENT

                                             VENUES                                                ASSESSMENT

           

Patient Care                        Emergency Room Rounds                     Monthly eval                                                                                                 

                                                and conferences

                                     

 

Med Knowledge                 Emergency Room Rounds                      Monthly eval

                                                and conferences

 

Professionalism                  Emergency Room Rounds                      Monthly eval

                                                and conferences

 

Interpersonal skills             Emergency Room Rounds                      Monthly eval

                                                and conferences                                    

 

PBL+I                                 Emergency Room Rounds                     Monthly eval

                                                and conferences

 

Systems Based Practice      Emergency Room Rounds                     Monthly eval 

                                                and conferences



2006 
Written by: Dr. Joseph DeLuca 

Reviewed by: Dr. Sharon Silbiger, Dr. Erica Spatz, Dr. Marta Rico
ć
Chief Resident,
Jan 11, 2012, 9:27 PM
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