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.


Level based rotation goals and objectives:

PGY-1 & PGY-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

Allergy/Immunology

Goals and objectives

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

b) Practice skills unique to Allergy

    • History and physical examination
    • Specific tests and procedures: use and interpretation: skin testing, desensitization
    • Preventive care: Avoidance of allergens
    • Patient education: Avoidance of allergens, availability of medications
    • Attitudes/values: Understand the psychosocial issues involved in patients with chronic allergic/immunologic diseases

c) Approach to presenting complaints/problems

    • Itching
    • Hives
    • Allergic rash
    • Upper respiratory complaints
    • Anaphylaxis

d) Specific diagnoses in Allergy

    • Hives
    • Anaphylaxis

e) Emergencies

    • Anaphylaxis
    • Exfoliation

f) Treatment modalities

    • Medication (antihistamines, steroids)
    • Desensitization

g) Technical skills:

    • Skin testing (familiarity)


Cardiology

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:

    • History and physical exam
    • Specific tests and procedures: use and interpretation: EKG, catheterization/angioplasty/stent placement, echocardiography, nuclear studies, tilt table testing, EP studies, holter monitor
    • Preventive care: risk factor modification
    • Patient education: risk factor modification, cardiac rehabilitation, diet, recognition of cardiac symptoms
    • Attitudes/values: Understand the impact of acute or chronic cardiac disease on the patient.

c) Approach to presenting complaints/problems:

    • Dyspnea
    • Chest pain
    • Palpitations
    • Edema
    • Claudication
    • Syncope

d) Specific diagnoses in Cardiology:

    • CAD: ischemia/myocardial infarction
    • Hypertension
    • Valvular disease
    • Arrhythmias
    • CHF
    • Pericardial disease
    • Hyperlipidemia

e) Emergencies:

    • Myocardial infarction/cardiogenic shock
    • Congestive heart failure/pulmonary edema
    • Malignant hypertension
    • Tamponade
    • Malignant arrhythmias

f) Treatment modalities:

    • Pharmacology
    • Pacemakers/Cardioversion/ICDs
    • Pericardiocentesis
    • CPR/ACLS
    • Stents/bypass grafting
    • Valvular surgery

g) Technical skills:

    • Central venous catheters
    • EKG interpretation


Dermatology

Goals and objectives

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

b) Practice skills unique to Dermatology:

    • History and physical examination
    • Specific tests and procedures: use and interpretation: skin biopsy, KOH prep, Wood’s light, Tzanck prep
    • Preventive care: sunscreen, sun avoidance, routine skin examinations, diet
    • Patient education: topical ointments, sun avoidance, yearly skin examinations
    • Attitudes/values: Understand the psychosocial burden carried by patients with serious skin diseases

c) Approach to presenting complaints/problems:

    • Rash
    • Ulcers
    • Itching
    • Other skin lesions (bullae)

d) Specific diagnoses in Dermatology:

    • Eczematous dermatitis
    • Drug eruptions
    • Psoriasis
    • Disorders of sebaceous glands
    • Disorders of hair
    • Disorders of dermis and dermal-epidermal interface
    • Bullous diseases
    • Syndromes involving blood vessels
    • SLE
    • Metabolic and Heritable Disorders
    • Infections (bacterial, fungal, viral)
    • Syphilis
    • Insect bites and infestations
    • Neoplasms (benign/malignant)

e) Emergencies

    • Exfoliation
    • Burns

f) Technical skills: Biopsy


Endocrinology

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:

    • History and physical examination
    • Specific tests and procedures: use and interpretation: hormonal assays, thyroid scanning/imaging, osteoporosis imaging
    • Preventive care: exercise, diet
    • Patient education: exercise, diet, replacement medications, foot care (dm), BS management (dm)
    • Attitudes/values: Understand the issues confronted by patients with endocrinologic diseases

c) Approach to presenting complaints/problems:

    • Weight changes
    • Thyroid nodules, goiter
    • Hirsutism
    • Amenorrhea
    • Galactorrhea
    • Incidental adrenal mass
    • Abnormal Calcium homeostasis
    • Symptoms of abnormal blood sugar
    • Diabetic foot problems
    • Impotence

d) Specific diagnoses in Endocrinology:

    • Differential diagnosis of hyperthyroidism and hypothyroidism; euthyroid sick syndrome
    • Thyroid cancer
    • Ovarian functional abnormalities
    • Cushings
    • Hyperaldosteronism
    • Addison’s disease
    • Pituitary disease (adenomas)
    • Diabetes mellitus
    • Diabetes insipidus
    • SIADH/Hypernatremia
    • Hyperparathyroidism
    • Pagets’ disease
    • Osteoporosis
    • Multiple Endocrine Neoplasias
    • Pheochromocytoma

e) Emergencies:

    • Diabetic Ketoacidosis
    • Hyperosmolality/Hypoosmolality (hyponatremia)
    • Hyper/Hypocalcemia
    • Myxedema coma
    • Addisonian crisis
    • Hypoglycemia

f) Treatment modalities:

    • Radioactive iodine
    • Medications for hyperthyroidism/hypothyroidism
    • Treatment for diabetes mellitus

g) Technical skills:

    • Fingerstick glucose monitoring


Gastroenterology

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

    • History and physical examination
    • 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
    • Preventive care: alcohol, typlenol, diet, colon cancer screening, hepatitis immunization
    • Patient education: alcohol, smoking, diet, fiber, alcohol rehabilitation
    • Attitudes/values: Understand the burden carried by patients with GI and liver disease and their families, understand the psychosocial dynamics surrounding alcoholism

c) Approach to presenting complaints/problems:

    • Abdominal pain
    • Diarrhea/constipation
    • Appetite/weight changes
    • Jaundice
    • Nausea and vomiting
    • Perianal discomfort
    • Dysphagia/non-cardiac chest pain
    • Abnormal liver tests
    • Post exposure hepatitis prophylaxis
    • Malabsorption
    • Liver failure
    • Iron deficiency anemia
    • Pharmacology and side effects of GI mediciation
    • Obesity
    • Malnutrition
    • Hematemesis, rectal bleeding, melena, GI bleeding

d) Specific diagnoses in Gastroenterology:

    • Esophagitis/Esophageal strictures/reflux, spasm, carcinoma
    • Achalasia
    • Ulcer disease
    • Gastric cancer/gastrinoma
    • Pancreatic insufficiency, pancreatitis, pancreatic carcinoma
    • Carcinoid syndrome
    • Irritable bowel syndrome
    • Colitis: ulcerative, Crohn’s, ischemic, infectious
    • Cholelithiasis, cholecystitis, cholangitis
    • Hepatitis: viral, drug induced
    • Alcoholic liver disease
    • Alpha I antitrypsin deficiency
    • Hemochromatosis, hemosiderosis
    • Primary biliary cirrhosis
    • Cirrhosis
    • Esophageal varices
    • Divericulosis/diverticulitis
    • Hepatorenal syndrome
    • Sprue
    • Whipple’s disease
    • AIDS and the GI tract
    • Appendicitis
    • Colonic polyps and cancer
    • Peritonitis

e) Emergencies:

    • GI bleeding
    • Acute hepatic failure
    • Acute cholangitis, acute choecystitis
    • Severe pancreatitis
    • Surgical emergencies: bowel performation, acute abdomen

f) Treatment modalities:

    • Drug therapy
    • Enteral alimentation, parenteral alimentation (TPN)
    • TIPS
    • Esophageal dilatation, dilatation of webs, strictures, rings
    • Schlerotherapy/banding of varices
    • ERCP with gall stone removal, papillotomy
    • Endoscopic treatment of bleeding lesions

g) Technical skills:

    • Nasogastric tube placement
    • Paracentesis


Geriatrics

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

    • History and physical examination
    • Specific tests and procedures: use and interpretation: psychosocial testing
    • Preventive care: falls, decubiti, diet, advanced directives
    • Patient and caregiver education: social interaction, falls, decubiti, diet, advanced directives
    • Attitudes/values: Understand the difficulties that some individuals face with age, respect patient dignity

c) Approach to presenting complaints/problems:

    • Confusion and other changes in behavior
    • Incontinence
    • Anemia
    • Weight loss
    • Changes in appetite
    • Bruises/fractures
    • Physical limitations: inability to ambulate, transfer etc
    • Elder care
    • Osteoporosis

d) Specific diagnoses in Geriatrics:

    • Dementia
    • Delirium
    • Incontinence
    • Parkinson’s disease
    • Anemia
    • Cancer
    • Depression
    • Polypharmacy
    • Elder abuse

e) Emergencies:

    • Elder abuse
    • Change in mental status

f) Treatment modalities:

    • Medications (including anticoagulation in the elderly)
    • Institution of supporting care (home care, day care, family meetings)
    • Surgery
    • Age appropriate health care maintenance

g) Technical skills:

    • Advanced directives
    • Skill with family meetings
    • Work with bioethics team
    • Work with health care team for disposition


Hematology

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

    • History and physical examination
    • 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
    • Preventive care: nutritional requirements for hematopoiesis, monitoring patients on anticoagulation
    • Patient education: living with chronic hematologic diseases (ex SS), medications, signs of bleeding, risks of transfusions
    • Attitudes/values: Understand the burden on patients living with chronic pain (ex SS)

c) Approach to presenting complaints/problems:

    • Pallor, orthostasis
    • Recurrent infections
    • Bleeding
    • Thrombosis
    • Lymphadenopathy
    • Splenomegaly

d) Specific diagnoses in Hematology:

    • Diseases of RBC: Anemias: aplastic, Fe deficiency, B12 deficiency, chronic disease, hemolytic, sickle cell; Hemoglobinopathies
    • Diseases of WBC: Neutropenia, Leukocytosis, Malignancies (leukemia, lymphoma, multiple myeloma)
    • Diseases of Platelets: thrombocytopenia, thrombocytosis
    • Hemostatic disorders: ex. Hemophilias, von Villebrand disease, circulating anticoagulants, ITP, DIC/TTP/HUS, hypercoagulable states
    • Hematologic complications of systemic conditions: ex: AIDS, connective tissue diseases, alcohol, organ failure (ex renal), sepsis, pregnancy
    • Hematologic complications of medical therapies: ex drug toxicities

e) Emergencies:

    • Pancytopenia
    • Severe anemia
    • Blast crisis/leukostasis
    • Superior vena cava syndrome
    • Hyperviscosity
    • Severe thrombocytopenia
    • DIC/HUS/TTP
    • Bleeding
    • Transfusion reactions

f) Treatment modalities:

    • Anticoagulation
    • Use of blood components
    • Use of growth factors
    • Selected antineoplastic agents
    • Pheresis
    • Other: ex: prednisone, gamma globulin, DDAVP

g) Technical skills:

    • Peripheral blood smear interpretation
    • Therapeutic phlebotomy
    • Bone marrow biopsy/aspiration


Infectious Diseases/HIV

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.

    • History and physical examination
    • 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
    • Preventive care: immunizations, TB screening, rheumatic fever prophylaxis, endocarditis prophylaxis, travel medicine, surgical wound prophylaxis, nosocomial infections
    • Patient education: value of immunizations, risk from highly contagious diseases, HIV risk reduction
    • Attitudes/values: Understand the needs of patients and families with chronic diseases (ex. HIV)

c) Approach to presenting complaints/problems:

    • Fever/FUO
    • Respiratory infections
    • Urinary infections
    • Intra abdominal infections
    • Diarrhea
    • Cardiovascular infections
    • CNS infections
    • Skin/soft tissue infections
    • Bone and joint infections
    • Sexually transmitted diseases
    • Nosocomial infections
    • Infections in compromised hosts
    • Infected prostheses
    • Postoperative and post traumatic infections
    • Travel medicine
    • Antibiotics: allergies and reactions
    • Antibiotic/ Antretroviral resistance
    • Sepsis syndromes

d) Specific diagnoses in I.D.:

    • HIV; HIV drug resistance
    • Pseudomembranous colitis
    • Hepatitis (viral)
    • Herpes infections
    • Atypical and typical pneumonias
    • Tick born diseases
    • Toxic shock syndrome
    • Sexually transmitted diseases (GC, syphilis, chlamydia)
    • Vibrio cholerae
    • Listeriosis
    • Meningitis (bacterial and viral)
    • Encephalitis
    • Fungal diseases
    • Cat scratch disease and bacillary angiomatosis
    • TB and other mycobacterial diseases
    • Amebiasis
    • Malaria
    • Infectious diarrhea

e) Emergencies:

    • Septic shock/ toxic shock
    • Overwhelming bacterial or fungal infection
    • Meningitis

f) Treatment modalities:

    • Antibiotics; Antiretrovirals; Antivirals
    • Surgery
    • Immunotherapy
    • Hematopoietic colony stimulating factors
    • Anti-toxins

g) Technical skills:

    • Gram stain and AFB stain
    • Lumbar puncture
    • Blood cultures


Nephrology

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

    • History and physical examination
    • Specific tests and procedures: use and interpretation: urinanalysis (with Uosm), sonography, CT/MRI, nuclear scans, renal biopsy
    • Preventive care: microalbuminuria in dm, monitoring of renal lab tests
    • Patient education: diet, adherence to antihypertension medications, symptoms of uremia, pre-dialysis counseling
    • Attitudes/values: understand the psychosocial issues surrounding chronic illness, dialysis and withdrawal of dialysis

c) Approach to presenting complaints/problems:

    • Dysuria
    • Hematuria
    • Edema anasarca
    • Flank pain
    • Changes in urine volume
    • Obstructive uropathy
    • Proteinuria/nephrotic syndrome
    • Glomerulonephritis
    • Use of nephrotoxic agents
    • Dosage modification in renal failure
    • Hypertension

d) Specific diagnoses in Nephrology:

    • Infections of the kidney
    • Acute renal failure
    • Chronic renal failure (including dialysis and transplantation)
    • Hereditary kidney diseases (ex Polycystic)
    • Electrolyte abnormalities (ex. Hypo/hypernatremia (SIADH, DI), hypo/hypercalcemia, hypo/hyperphosphatemia, hypo/hypermagnesemia, hypo/hyperkalemia)
    • Acid-base abnormalities
    • Renal complications of systemic diseases
    • Nephrolithiasis
    • Hypertension
    • Renal Tumors
    • Glomerular Diseases (nephrosis/nephritis)
    • Kidney diseases in pregnancy

e) Emergencies:

    • Acute hyperkalemia
    • Anuria
    • Severe acidosis/alkalosis
    • Uremia (indications for dialysis)
    • Hypertensive crisis

f) Treatment modalities:

    • Medications (ACEI, ARB, BP medications)
    • De-obstruction (stents, nephrostomy, lithotripsy)
    • Erythropoietin

g) Technical skills:

    • Familiarity with renal biopsy
    • Urinalysis interpretation
    • Fundoscopic exam


Neurology

Goals and objectives (supplemented by Neurology rotation)

    • Principles, physiology and basic science: Understand basic neurological pathways and how that translates into neurological function
    • Practice skills unique to Neurology
    • History and physical examination
    • Specific tests and procedures: use and interpretation: CT/MRI, EEG, LP
    • Preventive care: understand importance of BP control as it relates to CVA events
    • Patient education: BP control, importance of medication adherence, signs and symptoms of cerebral events
    • Attitudes/values: Understand the psychosocial issues in patients with chronic neurologic diseases

c) Approach to presenting complaints/problems:

    • Change in mental status
    • Seizures/Twitching
    • Focal weakness
    • Headache
    • Neck stiffness

d) Specific diagnoses in Neurology:

    • Coma
    • Headache
    • Seizures/status epilepticus
    • Disorders of gait and coordination
    • Disorders of mentation and language
    • Acute intracranial catastrophes
    • Extrapyramidal disorders
    • Demyelinating diseases
    • Central nervous system infections
    • Neurologic complications of AIDS
    • Psychogenic disorders with neurologic presentation
    • Myasthenia gravis, Guillain-Barre and other neurologic diseases with respiratory presentation
    • CVA/TIA
    • Indications for anticoagulation

e) Emergencies:

    • Acute change in mental status
    • Status epilepticus
    • Meningitis
    • Increased intracranial pressure

f) Treatment modalities:

    • Medications
    • Anticoagulation
    • Physical and occupational therapy

g) Technical skills:

    • Lumbar puncture
    • CT/MRI
    • Neurological examination


Oncology

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

    • History and physical examination
    • Specific tests and procedures: use and interpretation: biopsies, imaging modalities, tumor markers, cytology
    • Preventive care: environmental exposure, smoking cessation, alcohol cessation, diet, screening, genetic counseling
    • Patient education: appropriate cancer screening, self examination, diet, sunscreen/sun exposure, smoking cessation
    • 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:

    • Adenopathy
    • Mass/nodule
    • Cancer of unknown primary
    • Acute neurologic events
    • Superior vena cava obstruction
    • Electrolyte abnormalities (hypercalcemia, hyponatremia)
    • Pericardial tamponade
    • Infectious and hematologic complications of therapy
    • Weight loss
    • Hemoptysis and airway obstruction
    • Nausea and vomiting

d) Specific diagnoses in Oncology

    • Lung cancer
    • Head and Neck cancer
    • Breast cancer
    • Esophageal cancer
    • Gastric cancer
    • Pancreatic cancer
    • Hepatocellular cancer
    • Colorectal cancer
    • Prostate cancer
    • Bladder cancer
    • Renal cancer
    • Testicular cancer
    • Uterine cancer
    • Cervical cancer
    • Ovarian cancer
    • Lymphoma (Hodgkins/non-Hodgkins)
    • Leukemias
    • Osteosarcoma
    • Brain tumors
    • Skin cancer
    • Cancer related to HIV/post transplant

e) Emergencies:

    • Superior vena cava syndrome
    • Spinal cord compression
    • Brain metastases with increased intracranial pressure
    • Hypercalcemia
    • Tumor lysis syndrome
    • Pericardial tamponade
    • Infections
    • Cytopenias
    • GI obstruction
    • Obstructive uropathy
    • Hemolytic uremic syndrome

f) Treatment modalities:

    • Chemotherapy
    • Radiation therapy
    • Molecular targeted therapies
    • Surgery
    • Antiemetic therapy
    • Pain management
    • Nutritional support
    • Hospice care

f) Technical skills:

    • Bone marrow aspirate/biopsy (familiarity)


Pulmonary

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

    • History and physical examination
    • 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
    • Preventive care: smoking cessation, industrial exposure, environmental exposure, TB screening and prevention, DVT prophylaxis
    • Patient education: smoking cessation, breathing exercises, asthma education
    • Attitudes/values: Understand the issues faced by individuals with chronic pulmonary diseases

c) Approach to presenting complaints/problems:

    • Acute respiratory failure
    • Dyspnea
    • Cough
    • Hemoptysis
    • Chest pain
    • Hypoxia
    • Hypercapnia
    • Somnolence/sleep disturbance
    • Lung nodule
    • Pleural effusion
    • Wheezing
    • Anticoagulation therapy
    • Thoracentesis/Chest tube insertion

d) Specific diagnoses in Pulmonary:

    • Lung cancer
    • Pneumonias and other infections
    • Alpha I antitrypsin deficiency
    • Cystic fibrosis
    • Vasculitis
    • Sacrcoidosis
    • Drug toxicity
    • Pneumoconioses
    • ARDS
    • Pneumothorax
    • Empyema
    • COPD
    • AIDS related pulmonary diseases

e) Emergencies:

    • Acute respiratory failure
    • Tension pneumothorax
    • Lung collapse
    • Hemoptysis
    • Upper airway obstruction
    • Acute pulmonary embolus

f) Treatment modalities:

    • Oxygen therapy
    • Bronchodilator therapy
    • Antibiotic therapy
    • Mechanical ventilation
    • Anticoagulation/ IVC filter/thrombectomy procedures
    • Cancer chemotherapy

g) Technical skills:

    • ABG
    • Thoracentesis
    • Intubation (familiarity)
    • Skin testing
    • Mechanical ventilation


Rheumatology

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

    • History and physical examination
    • Specific tests and procedures: use and interpretation: arthrocentesis, synovial biopsy, arthroscopy, autoantibodies, serologic tests, MRI/CT/US, synovial fluid analysis
    • Preventive care: diet, osteoporosis prophylaxis, vaccines/infection prophylaxis
    • Patient education: coping with chronic disease and chronic pain, understand cytoxic drugs, joint protection, exercise
    • Attitudes/values: Understand the impact of chronic disease and chronic pain on patients

c) Approach to presenting complaints/problems:

    • Monoarticular arthritis
    • Polyarticular arthritis
    • Low back pain
    • Neck pain
    • Diffuse muscle pain
    • Raynaud’s phenomenon
    • Sicca syndrome
    • Uveitis
    • Breast implants
    • Rash/vasculitis
    • Glomerulonephritis associated with systemic disease
    • Entrapment syndromes

d) Specific diagnoses in Rheumatology:

    • RA/JRA
    • SLE
    • Antiphospholipid syndrome
    • Systemic schlerosis
    • MCTD
    • Sjogren’s syndrome
    • Myositis
    • Systemic necrotizing vasculitis
    • Cryoglobulinemia
    • Polymyalgia rheumatica
    • Temporal Arteritis
    • Polychondritis
    • Ankylosing spondylosis/Reiter’s syndrome
    • Psoriatic arthritis
    • Acute rheumatic fever
    • Osteoarthritis
    • Infectious arthritis
    • Lyme
    • Sarcoidosis
    • Gout/CPPD
    • Fibromyalgia
    • HIV associated arthropathy
    • Osteonecrosis
    • Osteoporosis
    • Reflex sympathetic dystrophy
    • Radiculopathy
    • Spinal stenosis

e) Emergencies:

    • Septic arthritis
    • Lupus crisis
    • Scleroderma renal crisis
    • Cervical spine subluxation
    • CNS vasculitis
    • Mesenteric vasculitis
    • Thrombosis

f) Treatment modalities:

    • NSAID (including COX-2 inhibitors)
    • Antimalarials
    • Penicillamine, Gold
    • Cytotoxic drugs (AZA, Methotrexate, chlorambucil, leflunimide, CTX)
    • Cyclosporin
    • Sulfasalazine
    • IL-1 inhibitors
    • TNF blockade
    • Steroids
    • IV IG
    • Plasmapheresis
    • Intraarticular therapy
    • Physical therapy
    • Synovial surgery
    • Joint replacement

g) Technical skills:

    • Arthrocentesis
    • Punch skin biopsy


Orthopedics

Goals and Objectives

a) Principles, physiology, and basic science:

b) Practice skills unique to Orthopedics

    • History and physical examination
    • Specific tests and procedures: autoantibodies, serologic tests, MRI/CT, synovial fluid analysis
    • Preventive care: diet, osteoporosis prophylaxis
    • Patient education: coping with chronic disease and chronic pain, joint protection, ROM and muscle strengthening exercises
    • Attitudes/values: Understand the impact of chronic disease and chronic pain on patients

c) Approach to presenting complaints/problems:

    • Monoarticular arthritis
    • Polyarticular arthritis
    • Low back pain
    • Neck Pain
    • Foot/Ankle pain/trauma
    • Fractures of the long bones
    • Joint swelling/effusions
    • Shoulder injuries
    • Knee injuries

d) Specific diagnoses in Orthopedics:

    • Septic arthritis
    • Herniated disc disease
    • Fractures (arm, leg, ankle/foot)
    • Ankle sprains
    • Tendonitis
    • Entrapment syndromes
    • Rotator cuff tear
    • Shoulder dislocation
    • Meniscal tears of knee
    • Ligament tears of knee
    • Osteoarthritis
    • Rheumatoid arthritis

e) Emergencies:

    • Septic arthritis
    • Cervical spine subluxation
    • Acute fractures (humerus, femur, tibia/fibula, ankle/foot)

f) Treatment modalities:

    • Joint aspiration
    • Setting of fracture
    • NSAIDS
    • Steriods
    • Joint replacement
    • Ace bandage
    • Tendon injections

g) Technical skills:

    • Arthrocentesis


General Surgery

Goals and Objectives

a) Principles, physiology, and basic science:

b) Practice skills unique to General Surgery

    • History and physical examination
    • Specific tests and procedures: CT Scan, ultrasound, MRI interpretation
    • Preventive care: diet
    • Patient education:
    • Attitudes/values: understanding patients’ psychosocial stress related to undergoing operative procedures

c) Approach to presenting complaints/problems:

    • Abdominal pain
    • Rectal bleeding
    • Hematemesis
    • Nausea and Vomiting
    • Nonhealing wounds
    • Post-op infections
    • Skin infection

d) Specific diagnoses in General Surgery:

    • Cholecystitis
    • Cholanigitis
    • Appendicitis
    • Diverticulitis
    • Pancreatitis
    • Perforated intestine
    • Hemorrhoids
    • Colonic AVM
    • Colitis
    • Wound infection
    • Post-op pneumonia, etc.
    • Cellulits
    • Skin abscess

e) Emergencies:

    • Cholecystitis
    • Cholangitis
    • Appendicitis
    • Perforated intestine
    • Colonic AVM

f) Treatment modalities:

    • Cholecystectomy
    • Appendectomy
    • Hemicolectomy
    • Hemorroidectomy
    • Supportive care: bowel rest/NPO
    • IV antibiotics
    • Wound care
    • Incision and drainage of abscess

g) Technical skills:

    • Incision and drainage of abscess
    • Wound care/dressing changes


Urology

Goals and Objectives

a) Principles, physiology, and basic science:

b) Practice skills unique to Urology

    • History and physical examination
    • Specific tests and procedures: urine dipstick, CT Scan, ultrasound, and MRI interpretation
    • Preventive care:
    • Patient education:
    • Attitudes/values: understanding patients’ psychosocial stress related to undergoing operative procedures

c) Approach to presenting complaints/problems:

    • Dysuria
    • Renal colic
    • Incontinence
    • Hematuria
    • Pelvic pain
    • Erectile dysfunction
    • Urinary hesitancy or frequency

d) Specific diagnoses in General Surgery:

    • Urinary tract infection
    • Pyelonephritis
    • Nephrolithiais
    • Stress incontinence
    • Overflow incontinence
    • Urinary obstruction
    • Erectile dysfunction
    • Benign prostatic hypertrophy
    • Prostate cancer
    • Bladder cancer
    • Renal tumors

e) Emergencies:

    • Urinary obstruction

f) Treatment modalities:

    • Surgical resection of tumors
    • Alpha blockers
    • Erectile dysfunction medication classes
    • Lithotripsy
    • Prostatectomy
    • Antibiotics
    • Kegel exercises
    • Foley catheter insertion

g) Technical skills:

    • Urine microscopic analysis
    • Foley catheter insertion
    • Pelvic exams


Gynecology

Goals and Objectives

a) Principles, physiology, and basic science:

b) Practice skills unique to Gynecology

    • History and physical examination: performing pelvic exams and collecting specimens (e.g. PAP smear, endocervical discharges)
    • Specific tests and procedures: wet mounts
    • Preventive care: safer sex counsel, family planning, contraception care
    • Patient education: safer sex counsel, contraception care
    • Attitudes/values: Understanding the impact of pregnancy or termination of pregnancy on patients’ psychological health

c) Approach to presenting complaints/problems:

    • Pelvic pain
    • Vaginal discharge
    • Dysuria

d) Specific diagnoses in Gynecology:

    • Pelvic Inflammatory Disease
    • Pregnancy
    • Ovarian Cyst
    • Ovarian Tortion
    • Urethritis
    • Urinary Tract Infection
    • Uterine Fibriods
    • Tubal Pregnancy

e) Emergencies:

    • Ovarian Tortion
    • Tubal Pregnancy

f) Treatment modalities:

    • Emergency Contraction
    • D & C

g) Technical skills:

    • Performing pelvic exams
    • Examining wet mounts, KOH Preps


Toxicology

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

    • Specific tests and procedures: use and interpretation
    • Preventive care: understand referral sources for detox
    • Patient education: withdrawal symptom education
    • 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:

    • Acute ingestion
    • Suicidality
    • Acute withdrawal symptoms
    • Chronic dependence

d) Specific diagnoses in Toxicology

    • Alcohol overdose
    • Alcohol withdrawal
    • Heroin overdose
    • Heroin withdrawal
    • Acetaminophen overdose
    • Chronic substance use

e) Emergencies:

    • Acute ingestion
    • Acute withdrawal

f) Treatment modalities:

    • Charcoal administration
    • Narcan administration
    • Psychiatric care

g) Technical skills

    • Placing an NGT tube


II. ROUNDS AND CONFERENCES

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.

Emergency Medicine