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Objectives to direct the training of emergency medicine residents on off-service rotations: Internal medicine I
Ibedoufnal~rEmergency
Medicine,
Volil,
pp 765-770,
‘rinted
1993
IRECT THE TRAINING OF E FF-SERVICE ROTATIONS: 1 arkharn, iProfessor
MD,
Fellow,*
m ?he USA
Copyright
C ‘1993 Pe, ~a:non
Y MEDIC MEDICIN
and Glenn C. ~~mil~~~,
*Fellow and Chair,
in Curriculum Design and Education, Wright State University School of Medicine, Department of Emergency Medicine, Wright State University School of Medicine, Dayton, Reprint Address: Glenn C. Hamilton, MD, MSM, FACEP, FACP, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401
internal
medicine;
2.0 Abdominal and ~ast~o~~te~t~~~ c&orders 2.1 Presentation and co~s~derat~~~ 2.12 constipation 2.1.3 Diarrhea 2.1.5 ~emat~mesis/me~en~/~e 2.1.6 Jaundice 2.2 Esophagus 2.2.3 Peptic esophagitis 2.2.5 Varices
icine covers a broad field of knowledge, it is itself often subspecialized. This is the first of a three-part set of objectives for an offservice rotation in general internal medicine. Starting with the first part of the core content of emergency medicine, these objectives include abdominal, cariovascular, cutaneous, and immune system disorers. The second part will cover biologic agents and hematologic disorders. The third part will cover the remainder, including hormonal, metabolic, musculoskeletal, nervous system, psychobehavioral, and uro-
2.3 Stomach
2.3.1 Gastritis 2.3.4 PUD 2.4 Small bowel and colon 2.4.3 ~~vertic~litis~~iverticnlosis 2.4.4 Functional bowel (aka IrritabI
These objectives are not meant to be an exhaustive listing of all the possible problems that could present in the emergency department. Rather, this represents the core material that can be used to guide the studies of emergency medicine resident.s during the course of their training. The structure of this training may be a formal off-service rotation or a didactic series integrated with an emergency medicine experience. The objecducation-Features
Onio
tives are a critical format and the resi This is the 24th article in a ~o~t~~~i~~ series of objectives to direct the training of em ditine residents on off-service ~ot~t~o~~” ering system is deri from the core ~~~~~e~tlisting developed by the ight State ~J~~~$r~~ty epartmerit of Emergent edici~~ .
q Abstract ernal Medicine is an essential but diverse first in a three-part set of objectives for field. This is an off-service rotation in general internal medicine. This seriesmay be used to guide the resident during the rotation or to serve as part of a teaching program integrated with didactic training and emergency department experience. q Keywords - objectives; training; emergency medicine, residents
Press ,-(a.
2.4.10 Mesenteric t~rombosis/i~~a.r~~~~ labsorption syndr itonitis (see also tives)
articles focusing on the training of emergency physicians and the a~~:~~s~~~t~~~ of resi-
765
766
2.6 Liver and biliary tract 2.6.1 Cholecystitis 2.6.4 Cirrhosis 2.6.5 Hepatic failure 2.6.6 Hepatitis 2.7 Pancreas 2.7.1 Pancreatitis 2.7.3 Pancreatic insufficiency 5 .O Immunology 5.2 Hypersensitivity 5.2.1 Anaphylaxis 5.2.2 Angioneurotic edema 5.2.3 Serum sickness 5.3 Autoimmune disease 5.3.1 Rheumatoid arthritis (RA) 5.3.2 Systemic lupus erythematosus (SLE) 5.3.3 Scleroderma 5.3.4 Polymyositis/Dermatomyositis 5.4 Immunodeficiency syndromes 5.4.1 Acquired immune deficiency syndromes (AIDS) 5.5 Vaculitis syndromes 2.0 Abdominal and gastrointestinal disorders 2.1 Presentation and consideration 2.1.2 Constipation 1. Given a patient with the complaint of constipation, perform an appropriate history and physical examination, outline a differential diagnosis and initial therapy. Reference: (2) Harrison’s, pages 257-8. 2. List four groups of causes of constipation. Reference: (2) Harrison’s page 258.
Marla Markham
and Glenn C. Hamilton
1. Describe an appropriate history and physical examination for a patient presenting with upper or lower gastrointestinal (GI) bleeding. References: (2) Harrison’s page 261-4; Hamilton, pages 104-21. 2. Detail appropriate initial diagnostic and stabilization procedures for a patient presenting with upper or lower GI bleeding. References: (2) Harrison’s pages 261-4; Hamilton, pages 104-21, 3. List 6 different diagnostic possibilities in a patient with upper GI hemorrhage. References: (2) Harrison’s pages 261-2; Hamilton, page 111. 4. List which patients can be safely discharged home with self-care instructions. Reference: (1) Hamilton, page 120. 5. Given a patient with bleeding esophageal varices, be able to insert a Sengstaken-Blakemore tube under attending supervision, including a discussion of indications. Reference: (3) Hedges and Roberts, pages 649-55. 6. Given a patient with rectal pain or bleeding, perform and interpret an anoscopic examination. Reference: Hedges and Roberts, pages 696-7. 2.1.6 Jaundice 1. Given a patient presenting with jaundice, perform an appropriate history and physical examination, describe appropriate initial diagnostic evaluation, and list a differential diagnosis. Reference: (2) Harrison’s pages 264-8. 2. Given the results from two different paracenteses, differentiate between transudate and exudate and give a differential diagnosis for each. Reference: (2) Harrison’s page 270.
2.1.3 Diarrhea 1. Select the appropriate elements of a history and physical examination for a patient with diarrhea and outline a differential diagnosis and therapy for this patient. References: (2) Harrison’s, pages 257-8; (1) Hamilton, pages 122-35. 2. List 5 causes of diarrhea likely to have fecal leukocytes present in a smear. Reference: (1) Hamilton, page 127. 3. Demonstrate the procedure for preparation of smear for fecal leukocytes. Reference: (3) Hedges and Roberts, page 1068. 4. Discuss which patients need admission for diarrhea, Reference: (1) Hamilton, page 133. 5. Describe appropriate discharge instructions for patients with infectious diarrhea. Reference: (1) Hamilton, page 135. 2.1.5 Hematemesis/Melena/Hematochezia
2.2 Esophagus 2.2.3 Peptic esophagitis 1. Describe the differential diagnosis of peptic esophagitis. Reference: (2) Harrison’s pages 1226-7. 2. List pharmacologic and possible surgical therapy appropriate for a patient with peptic esophagitis. Harrison’s p. 1227. 2.2.5 Varices 1. Describe the pathophysiologic alteration that results in esophageal varices. Reference: (2) Harrison’s page 1346. 2. Explain which of the listed historical and physical points are most consistent with esophageal varices. Reference: (2) Harrison’s p. 1346. a) bright red profuse upper GI bleed b) epigastric pain
Bbjectlves-lrternai
767
Medicine
c) antispasmodics d) stimulant cathartics e) liquid diet f) arrangement for barium procedure
c) hemorrhoids d) history of alcoholism/cirrhosis e) heavy aspirin use 2.3 Stomach 2.3.1 Gastritis 1. Bn suspected gastritis, describe the appropriate initial therapy and disposition of this patient. Harrison's pzge 1244-8. 2.3 4 Peptic Ulcer Disease (PUD) 1. In suspected tic ulcer disease, describe the appropriate ini diagnostic tests, appropriate initial therapy, and disposition for this patient. Reference: (2) Harrison’s pages 1230-8. 2. List three indications for surgery in peptic ulcer eference: (2) Harrison’s pages 1238-9. 3. Match the following points with either gastric or duodenal ulcer. Reference: (2) Harrison’s pages 9233 and 1237. a) malignancy must be carefully excluded b) pain is characteristically rhythmic, periodic, and chronic c) food may exacerbate pain d) gastric outlet obstruction is a complication
~~~~a as diagnostic
2.4.5 Castroenteritis (see 2.4.7 Inflammatory bowel disease ~~~lsi~a~, alid patho 1. Contrast key his differences of Cr isease and “%‘icemtiw tis (for example, are of ~~§~r~~~~t~sti~a~tract not] J rectal involveinvolved, diarrhea [bloody ference: (2) Harrisment, therapy, prognosis). on’s, pages 1268-77. esenteric thrornbosis/i~~a~~t~~ escribe typical ~re~~rati~n and initial stabilizaefertion of a exe: (2) 2.4.13 ~alab§~r~tio~
syndrome
1. Describe the typical history of malabsorption syndrome. rison’s, pages 1259-60.
2.4 Smalii bowel and colon 2.4.3 Diverticulitis/Diverticulosis
2.4.24 Peritonitis
?. Describe the typical history and physical findings of a patient with diverticulosis. Reference: (2) r&son’s, pages 1283-4. 2. ch the listed therapeutics or findings with eidiverticulosis or diverticulitis. Reference: (2) Harrison’s pages 1283-4. a) low residue diet b) high fiber diet c) antibiotics d) pain and fever e) bright red rectal bleeding
1. List some characteristics of peritoneal pain. ence: (2) Harrison’s, page f&T, 2. List 4 causes of peritonitis ira the tient. Reference: (2) Harrison’s, pa
2.4.4 Functiona drome)
bowel (aka irritable
(see also General Surgery Objec-
tives)
bowel syn-
ibe the typical history and differential diagof a patient with functional bowel disease. ference: (2) Harrison’s, page 1286. 2. The initial therapy of a patient with functional bowel disease could include which of those listed. Reference: (2) Harrison’s page 1286. ) antacids ) bulk-forming agents
2.6 Liver and biliary tract 2.6.1 Gholecystitis
2. Describe the typical ~rese~tat~~~s and a initial therapy of a patient wi erence: (2) Harrison’s, pages 3. List 3 complications of cholel eference: (2) Harrison’s, pages 1363-4.
1.
2.6.4 Cirrhosis 1. List the 3 major c sis. Reference: (2) 2. Describe the spectrum and ~~~~~~s~~ ease due to alcohol ~o~s~rn~tio~, Harrison’s, page 1341.
768
Marla Markham
2.6.5 Hepatic failure 1. Describe the presentation and therapy of a patient with hepatic failure. Reference: (2) Harrison’s, pages 1340-2.
2.
3. 2.6.6 Hepatitis 1 Differentiate between hepatitis A and hepatitis B in terms of natural history, presentation, laboratory evaluation, and therapy. Include incubation times, onset, age preference, transmission route, severity, prognosis, progression to chronicity, prophylaxis, and carrier states. Reference: (2) Harrison’s, pages 1328-32. 2. Outline the management of a “needle stick” with a needle from a patient with either unknown hepatitis status, known hepatitis B, or known hepatitis A. Reference: (1) Hamilton, pages 333-43. 3. Describe the recommendations for hepatitis B vaccination and how to administer it. Reference: (1) Hamilton, page 340. 4. List 4 criteria used to determine whether or not admission is needed for a patient with either hepatitis A or hepatitis B. Reference: (2) Harrison’s, page 1330. 2.7 Pancreas 2.7.1 Pancreatitis
4.
5. 6.
tic and anaphylactoid reaction. Reference: (1) Hamilton, page 299. Identify 3 common categories of items that can cause anaphylaxis. Reference: (1) Hamilton, page 304. List 4 signs/symptoms in 4 major organ systems that can be affected in anaphylaxis. Reference: (1) Hamilton, page 305, (see Table 10-l) List the 2 major life-threatening problems in anaphylaxis and how to elicit them in the history. Reference: (1) Hamilton, page 302. Discuss initial management of a patient in anaphylaxis. Reference: (1) Hamilton, pages 299-311. Match the following clinical presentations with the appropriate treatment modalities: a. urticarial rash only 1. Benadryl b. respiratory distress 2. corticosteroids c. rash, hypotension 3. epinephrine d. laryngospasm, 4. oxygen hypotension 5. IV fluids 6. cardiac monitoring 7. intubation
7. Describe those who must be admitted versus those who can be safely discharged home from the ED and specify their plan. Reference: (1) Hamilton, page 310. 5.2.2 Angioneurotic
1. List 6 causes of pancreatitis. Reference: (2) Harrison’s, pages 1378-9. 2. List a differential diagnosis for hyperamylasemia. Reference: (2) Harrison’s, page 1371. 3. List appropriate initial therapy for a patient with acute pancreatitis. Reference: (2) Harrison’s, page 1376. 4. Describe how chronic pancreatitis may be discerned on x-ray study. Reference: (2) Harrison’s, page 1380. 2.7.3 Pancreatic insufficiency 1. Describe the pathophysiologic alterations that occur secondary to endocrine and exocrine pancreatic insufficiency. Reference: (2) Harrison’s, page 1379.
and Glenn C. Hamilton
edema
1. Define angioneurotic edema and its pathophysiology. Reference: (2) Harrison’s, pages 1425-6. 2. Given a clinical presentation or actual slides identify a) dermographism, b) solar urticaria, c) cholinergic urticaria, d) cold urticaria, e) contact urticaria, f) hereditary angioedema. Reference: (2) Harrison’s, pages 1425-6. 3 Match the diagnosis with the key diagnostic points: a. dermatographia 1. new clothing 2. autosomal dominant b . cholinergic urticaria 3. fades typically in 30 c. hereditary minutes angioedema 4. exercise with sweating d. light urticaria 5. history of collagen e. contact urticaria vascular disease 5.2.3 Serum sickness
5.0 Immunology 5.2 Hypersensitivity 5.2.1. Anaphylaxis 1. Discuss the pathophysiologic
basis for anaphylac-
1. Describe the pathophysiology of serum sickness. Reference: (2) Harrison’s, page 1430; (4) Rosen, page 2403. 2. List 3 commonly occurring signs and symptoms
Objectives-Internal
of serum sickness. Reference: (2) Harrison’s, page 1430.
3. List 4 commonly used drugs that may precipitate seeference: (2) Harrison’s, page 1430. 5.3 A~toimm~ne disease 5.3.1 Rheumatoid arthritis (RA) I. Be familiar
rbeum~toid
with the age and sex distribution of eference: (2) Harrison’s, arthritis.
2.
e pathophysiology of RA as it pertains to the articular surface. Reference: (2) Harrison’s,
3.
ate a working knowledge of the listed extraarticular manifestations of RA and indicate which might present emergently. Reference: (2) Marrison’s, pages 1438-9. a. rheumatoid nodules b . vasculitis c. CNS manifestations d. cardiac manifestations e. pulmonary complications f. renal involvement g. ocular manifestations
4. Given a set of plain radiographs,
5.
4.
7.
8.
“69
Medicine
identify a) RA, b) degenerative joint disease, c) gout, d) pseudogout. Reference: (2) Harrison’s, page 1439. List 3 or 4 appropriate initial laboratory tests in a patient suspected of having RA. Reference: (2) Harrison”s, page 1439. Given the following synovial fluid results, match th dings with the probable etiology: a. C > 50,000; low viscosity opaque appearance, poor clot. 1. septic joint .WBC=l, high viscosity, clear, good clot 2. normal j C = 1,000, yellow fluid, low viscosity, poor clot 3. RA List 5 of the American Rheumatism Association’s criteria for diagnosis of RA. Reference: (2) Harrison’s, page 1440. Given a brief clinical scenario, match the listed medications with the indications for usages and their potential complications. Reference: (2) Harrison’s, page 1442. a. aspirin b. nonsteroidal antiinflammatory agents . goid . penicillamine
5.3.2 Systemic lupus erythematosus (SLE)
1. Select from a list the sentence that best represents c pathowhat is currently understood to be t kXXlfS, Refere pbysiology of lupus. page 1432. 2. Identify key SLE to sex and age. 432. 3. List 5 of the 14 di
ostic criteria for SLE a umatism A~s~~~~~~~I~~ by the American ence: (2) Harrison’s, page 143 cognize or describe the SLE involve 4. ted areas and indicate which gently. Reference: (2) ~arriso~~s, pages 1432-5. a. joints 5. skin c. cardiopulmonary d. renal e. CNS f. GI g. hair 5.
scribe an appropriate initial the emergency depa petted of having SLE. 1435.
e two drugs that have en. Kiowa to precipitate SLE-like syndromes. efereme: (2) Harrispage 1436. 7. onstrate familiarity with the rties utilized in SLE ~~t~e~~s. rrison’s, page 1436. 8. aware of the camplicati~ ment with the above drugs. 6.
5.3.3 Scleroderma I. Identify> at the cellular level, of scleroderma. 1443. 2. List 3 life-threatening
corn lications of this dis-
ease. Reference: (2) 3. List skin and vascular disease. Reference: (2) 5.3.4 ~oIymyosiii~/ 1. Describe the 3 omyositis.
Refer~~~ce~(
riate laboratory ing the potential fo gency department . 2108.
tests ti> begin evaluat~r~os~t~sin the emer: (2) ~~~ri~~~‘s~ page
770
Marla Markham
5.4 Immunodeficiency syndromes 5.4.1 Acquired immune deficiency syndromes (AIDS)
1. Give a clinical definition of AIDS. Reference: (2) Harrison’s, page 1402. 2. List the 5 groups of persons at high risk for contracting AIDS. Reference: (2) Harrison’s, page 1403. 3. Discuss involvement of each of the listed organ systems in AIDS. Reference: (2) Harrison’s, pages 1405-7. a. central nervous system b. cardiovascular c. pulmonary d. gastrointestinal e. skin
and Glenn C. Hamilton
4. List 3 infectious diseases commonly seen in AIDS patients. Reference: (2) Harrison’s, pages 1406-7. 5. Given a patient in whom AIDS is suspected, initiate a laboratory workup. Reference: (2) Harrison’s, page 1409. 6. Be familiar with measures to prevent the spread of AIDS among health care personnel. Reference: (2) Harrison’s, page 1410. 7. What percentage of health care workers will seroconvert after exposure via needlesticks. Reference: Hamilton, page 336. 5.5 Vasculitis syndromes 1. Given 3 clinical data bases, match the correct vasculitis syndrome, including systemic necrotizing vasculitis, hypersensitivity vasculitis, giant cell arteritis. Reference: (2) Harrison’s, pages 1457-62.
REFERENCES 1. Hamilton G, Sanders A, Strange G, Trott A. Emergency medicine: an approach to clinical problem-solving. Philadelphia: WB Saunders; 1991. 2. *Wilson J, Braunwald E, Isselbacher K, et al. Harrison’sprincipies of internal medicine. 12th ed. New York: McGraw Hill; 1991.
*Indicates briefcase.
references
that are in the Internal
Medicine
3. Hedges J, Roberts J. CIinical procedures tine. 2nd ed. Philadelphia: WB Saunders; 4. Rosen P, Barker FJ II, Barkin RM, et al. concepts and clinical practice, 3rd ed. Mosby; 1991.
in emergency medi1991. Emergency medicine: St. Louis, Missouri:
Medicine,
Volil,
pp 765-770,
‘rinted
1993
IRECT THE TRAINING OF E FF-SERVICE ROTATIONS: 1 arkharn, iProfessor
MD,
Fellow,*
m ?he USA
Copyright
C ‘1993 Pe, ~a:non
Y MEDIC MEDICIN
and Glenn C. ~~mil~~~,
*Fellow and Chair,
in Curriculum Design and Education, Wright State University School of Medicine, Department of Emergency Medicine, Wright State University School of Medicine, Dayton, Reprint Address: Glenn C. Hamilton, MD, MSM, FACEP, FACP, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401
internal
medicine;
2.0 Abdominal and ~ast~o~~te~t~~~ c&orders 2.1 Presentation and co~s~derat~~~ 2.12 constipation 2.1.3 Diarrhea 2.1.5 ~emat~mesis/me~en~/~e 2.1.6 Jaundice 2.2 Esophagus 2.2.3 Peptic esophagitis 2.2.5 Varices
icine covers a broad field of knowledge, it is itself often subspecialized. This is the first of a three-part set of objectives for an offservice rotation in general internal medicine. Starting with the first part of the core content of emergency medicine, these objectives include abdominal, cariovascular, cutaneous, and immune system disorers. The second part will cover biologic agents and hematologic disorders. The third part will cover the remainder, including hormonal, metabolic, musculoskeletal, nervous system, psychobehavioral, and uro-
2.3 Stomach
2.3.1 Gastritis 2.3.4 PUD 2.4 Small bowel and colon 2.4.3 ~~vertic~litis~~iverticnlosis 2.4.4 Functional bowel (aka IrritabI
These objectives are not meant to be an exhaustive listing of all the possible problems that could present in the emergency department. Rather, this represents the core material that can be used to guide the studies of emergency medicine resident.s during the course of their training. The structure of this training may be a formal off-service rotation or a didactic series integrated with an emergency medicine experience. The objecducation-Features
Onio
tives are a critical format and the resi This is the 24th article in a ~o~t~~~i~~ series of objectives to direct the training of em ditine residents on off-service ~ot~t~o~~” ering system is deri from the core ~~~~~e~tlisting developed by the ight State ~J~~~$r~~ty epartmerit of Emergent edici~~ .
q Abstract ernal Medicine is an essential but diverse first in a three-part set of objectives for field. This is an off-service rotation in general internal medicine. This seriesmay be used to guide the resident during the rotation or to serve as part of a teaching program integrated with didactic training and emergency department experience. q Keywords - objectives; training; emergency medicine, residents
Press ,-(a.
2.4.10 Mesenteric t~rombosis/i~~a.r~~~~ labsorption syndr itonitis (see also tives)
articles focusing on the training of emergency physicians and the a~~:~~s~~~t~~~ of resi-
765
766
2.6 Liver and biliary tract 2.6.1 Cholecystitis 2.6.4 Cirrhosis 2.6.5 Hepatic failure 2.6.6 Hepatitis 2.7 Pancreas 2.7.1 Pancreatitis 2.7.3 Pancreatic insufficiency 5 .O Immunology 5.2 Hypersensitivity 5.2.1 Anaphylaxis 5.2.2 Angioneurotic edema 5.2.3 Serum sickness 5.3 Autoimmune disease 5.3.1 Rheumatoid arthritis (RA) 5.3.2 Systemic lupus erythematosus (SLE) 5.3.3 Scleroderma 5.3.4 Polymyositis/Dermatomyositis 5.4 Immunodeficiency syndromes 5.4.1 Acquired immune deficiency syndromes (AIDS) 5.5 Vaculitis syndromes 2.0 Abdominal and gastrointestinal disorders 2.1 Presentation and consideration 2.1.2 Constipation 1. Given a patient with the complaint of constipation, perform an appropriate history and physical examination, outline a differential diagnosis and initial therapy. Reference: (2) Harrison’s, pages 257-8. 2. List four groups of causes of constipation. Reference: (2) Harrison’s page 258.
Marla Markham
and Glenn C. Hamilton
1. Describe an appropriate history and physical examination for a patient presenting with upper or lower gastrointestinal (GI) bleeding. References: (2) Harrison’s page 261-4; Hamilton, pages 104-21. 2. Detail appropriate initial diagnostic and stabilization procedures for a patient presenting with upper or lower GI bleeding. References: (2) Harrison’s pages 261-4; Hamilton, pages 104-21, 3. List 6 different diagnostic possibilities in a patient with upper GI hemorrhage. References: (2) Harrison’s pages 261-2; Hamilton, page 111. 4. List which patients can be safely discharged home with self-care instructions. Reference: (1) Hamilton, page 120. 5. Given a patient with bleeding esophageal varices, be able to insert a Sengstaken-Blakemore tube under attending supervision, including a discussion of indications. Reference: (3) Hedges and Roberts, pages 649-55. 6. Given a patient with rectal pain or bleeding, perform and interpret an anoscopic examination. Reference: Hedges and Roberts, pages 696-7. 2.1.6 Jaundice 1. Given a patient presenting with jaundice, perform an appropriate history and physical examination, describe appropriate initial diagnostic evaluation, and list a differential diagnosis. Reference: (2) Harrison’s pages 264-8. 2. Given the results from two different paracenteses, differentiate between transudate and exudate and give a differential diagnosis for each. Reference: (2) Harrison’s page 270.
2.1.3 Diarrhea 1. Select the appropriate elements of a history and physical examination for a patient with diarrhea and outline a differential diagnosis and therapy for this patient. References: (2) Harrison’s, pages 257-8; (1) Hamilton, pages 122-35. 2. List 5 causes of diarrhea likely to have fecal leukocytes present in a smear. Reference: (1) Hamilton, page 127. 3. Demonstrate the procedure for preparation of smear for fecal leukocytes. Reference: (3) Hedges and Roberts, page 1068. 4. Discuss which patients need admission for diarrhea, Reference: (1) Hamilton, page 133. 5. Describe appropriate discharge instructions for patients with infectious diarrhea. Reference: (1) Hamilton, page 135. 2.1.5 Hematemesis/Melena/Hematochezia
2.2 Esophagus 2.2.3 Peptic esophagitis 1. Describe the differential diagnosis of peptic esophagitis. Reference: (2) Harrison’s pages 1226-7. 2. List pharmacologic and possible surgical therapy appropriate for a patient with peptic esophagitis. Harrison’s p. 1227. 2.2.5 Varices 1. Describe the pathophysiologic alteration that results in esophageal varices. Reference: (2) Harrison’s page 1346. 2. Explain which of the listed historical and physical points are most consistent with esophageal varices. Reference: (2) Harrison’s p. 1346. a) bright red profuse upper GI bleed b) epigastric pain
Bbjectlves-lrternai
767
Medicine
c) antispasmodics d) stimulant cathartics e) liquid diet f) arrangement for barium procedure
c) hemorrhoids d) history of alcoholism/cirrhosis e) heavy aspirin use 2.3 Stomach 2.3.1 Gastritis 1. Bn suspected gastritis, describe the appropriate initial therapy and disposition of this patient. Harrison's pzge 1244-8. 2.3 4 Peptic Ulcer Disease (PUD) 1. In suspected tic ulcer disease, describe the appropriate ini diagnostic tests, appropriate initial therapy, and disposition for this patient. Reference: (2) Harrison’s pages 1230-8. 2. List three indications for surgery in peptic ulcer eference: (2) Harrison’s pages 1238-9. 3. Match the following points with either gastric or duodenal ulcer. Reference: (2) Harrison’s pages 9233 and 1237. a) malignancy must be carefully excluded b) pain is characteristically rhythmic, periodic, and chronic c) food may exacerbate pain d) gastric outlet obstruction is a complication
~~~~a as diagnostic
2.4.5 Castroenteritis (see 2.4.7 Inflammatory bowel disease ~~~lsi~a~, alid patho 1. Contrast key his differences of Cr isease and “%‘icemtiw tis (for example, are of ~~§~r~~~~t~sti~a~tract not] J rectal involveinvolved, diarrhea [bloody ference: (2) Harrisment, therapy, prognosis). on’s, pages 1268-77. esenteric thrornbosis/i~~a~~t~~ escribe typical ~re~~rati~n and initial stabilizaefertion of a exe: (2) 2.4.13 ~alab§~r~tio~
syndrome
1. Describe the typical history of malabsorption syndrome. rison’s, pages 1259-60.
2.4 Smalii bowel and colon 2.4.3 Diverticulitis/Diverticulosis
2.4.24 Peritonitis
?. Describe the typical history and physical findings of a patient with diverticulosis. Reference: (2) r&son’s, pages 1283-4. 2. ch the listed therapeutics or findings with eidiverticulosis or diverticulitis. Reference: (2) Harrison’s pages 1283-4. a) low residue diet b) high fiber diet c) antibiotics d) pain and fever e) bright red rectal bleeding
1. List some characteristics of peritoneal pain. ence: (2) Harrison’s, page f&T, 2. List 4 causes of peritonitis ira the tient. Reference: (2) Harrison’s, pa
2.4.4 Functiona drome)
bowel (aka irritable
(see also General Surgery Objec-
tives)
bowel syn-
ibe the typical history and differential diagof a patient with functional bowel disease. ference: (2) Harrison’s, page 1286. 2. The initial therapy of a patient with functional bowel disease could include which of those listed. Reference: (2) Harrison’s page 1286. ) antacids ) bulk-forming agents
2.6 Liver and biliary tract 2.6.1 Gholecystitis
2. Describe the typical ~rese~tat~~~s and a initial therapy of a patient wi erence: (2) Harrison’s, pages 3. List 3 complications of cholel eference: (2) Harrison’s, pages 1363-4.
1.
2.6.4 Cirrhosis 1. List the 3 major c sis. Reference: (2) 2. Describe the spectrum and ~~~~~~s~~ ease due to alcohol ~o~s~rn~tio~, Harrison’s, page 1341.
768
Marla Markham
2.6.5 Hepatic failure 1. Describe the presentation and therapy of a patient with hepatic failure. Reference: (2) Harrison’s, pages 1340-2.
2.
3. 2.6.6 Hepatitis 1 Differentiate between hepatitis A and hepatitis B in terms of natural history, presentation, laboratory evaluation, and therapy. Include incubation times, onset, age preference, transmission route, severity, prognosis, progression to chronicity, prophylaxis, and carrier states. Reference: (2) Harrison’s, pages 1328-32. 2. Outline the management of a “needle stick” with a needle from a patient with either unknown hepatitis status, known hepatitis B, or known hepatitis A. Reference: (1) Hamilton, pages 333-43. 3. Describe the recommendations for hepatitis B vaccination and how to administer it. Reference: (1) Hamilton, page 340. 4. List 4 criteria used to determine whether or not admission is needed for a patient with either hepatitis A or hepatitis B. Reference: (2) Harrison’s, page 1330. 2.7 Pancreas 2.7.1 Pancreatitis
4.
5. 6.
tic and anaphylactoid reaction. Reference: (1) Hamilton, page 299. Identify 3 common categories of items that can cause anaphylaxis. Reference: (1) Hamilton, page 304. List 4 signs/symptoms in 4 major organ systems that can be affected in anaphylaxis. Reference: (1) Hamilton, page 305, (see Table 10-l) List the 2 major life-threatening problems in anaphylaxis and how to elicit them in the history. Reference: (1) Hamilton, page 302. Discuss initial management of a patient in anaphylaxis. Reference: (1) Hamilton, pages 299-311. Match the following clinical presentations with the appropriate treatment modalities: a. urticarial rash only 1. Benadryl b. respiratory distress 2. corticosteroids c. rash, hypotension 3. epinephrine d. laryngospasm, 4. oxygen hypotension 5. IV fluids 6. cardiac monitoring 7. intubation
7. Describe those who must be admitted versus those who can be safely discharged home from the ED and specify their plan. Reference: (1) Hamilton, page 310. 5.2.2 Angioneurotic
1. List 6 causes of pancreatitis. Reference: (2) Harrison’s, pages 1378-9. 2. List a differential diagnosis for hyperamylasemia. Reference: (2) Harrison’s, page 1371. 3. List appropriate initial therapy for a patient with acute pancreatitis. Reference: (2) Harrison’s, page 1376. 4. Describe how chronic pancreatitis may be discerned on x-ray study. Reference: (2) Harrison’s, page 1380. 2.7.3 Pancreatic insufficiency 1. Describe the pathophysiologic alterations that occur secondary to endocrine and exocrine pancreatic insufficiency. Reference: (2) Harrison’s, page 1379.
and Glenn C. Hamilton
edema
1. Define angioneurotic edema and its pathophysiology. Reference: (2) Harrison’s, pages 1425-6. 2. Given a clinical presentation or actual slides identify a) dermographism, b) solar urticaria, c) cholinergic urticaria, d) cold urticaria, e) contact urticaria, f) hereditary angioedema. Reference: (2) Harrison’s, pages 1425-6. 3 Match the diagnosis with the key diagnostic points: a. dermatographia 1. new clothing 2. autosomal dominant b . cholinergic urticaria 3. fades typically in 30 c. hereditary minutes angioedema 4. exercise with sweating d. light urticaria 5. history of collagen e. contact urticaria vascular disease 5.2.3 Serum sickness
5.0 Immunology 5.2 Hypersensitivity 5.2.1. Anaphylaxis 1. Discuss the pathophysiologic
basis for anaphylac-
1. Describe the pathophysiology of serum sickness. Reference: (2) Harrison’s, page 1430; (4) Rosen, page 2403. 2. List 3 commonly occurring signs and symptoms
Objectives-Internal
of serum sickness. Reference: (2) Harrison’s, page 1430.
3. List 4 commonly used drugs that may precipitate seeference: (2) Harrison’s, page 1430. 5.3 A~toimm~ne disease 5.3.1 Rheumatoid arthritis (RA) I. Be familiar
rbeum~toid
with the age and sex distribution of eference: (2) Harrison’s, arthritis.
2.
e pathophysiology of RA as it pertains to the articular surface. Reference: (2) Harrison’s,
3.
ate a working knowledge of the listed extraarticular manifestations of RA and indicate which might present emergently. Reference: (2) Marrison’s, pages 1438-9. a. rheumatoid nodules b . vasculitis c. CNS manifestations d. cardiac manifestations e. pulmonary complications f. renal involvement g. ocular manifestations
4. Given a set of plain radiographs,
5.
4.
7.
8.
“69
Medicine
identify a) RA, b) degenerative joint disease, c) gout, d) pseudogout. Reference: (2) Harrison’s, page 1439. List 3 or 4 appropriate initial laboratory tests in a patient suspected of having RA. Reference: (2) Harrison”s, page 1439. Given the following synovial fluid results, match th dings with the probable etiology: a. C > 50,000; low viscosity opaque appearance, poor clot. 1. septic joint .WBC=l, high viscosity, clear, good clot 2. normal j C = 1,000, yellow fluid, low viscosity, poor clot 3. RA List 5 of the American Rheumatism Association’s criteria for diagnosis of RA. Reference: (2) Harrison’s, page 1440. Given a brief clinical scenario, match the listed medications with the indications for usages and their potential complications. Reference: (2) Harrison’s, page 1442. a. aspirin b. nonsteroidal antiinflammatory agents . goid . penicillamine
5.3.2 Systemic lupus erythematosus (SLE)
1. Select from a list the sentence that best represents c pathowhat is currently understood to be t kXXlfS, Refere pbysiology of lupus. page 1432. 2. Identify key SLE to sex and age. 432. 3. List 5 of the 14 di
ostic criteria for SLE a umatism A~s~~~~~~~I~~ by the American ence: (2) Harrison’s, page 143 cognize or describe the SLE involve 4. ted areas and indicate which gently. Reference: (2) ~arriso~~s, pages 1432-5. a. joints 5. skin c. cardiopulmonary d. renal e. CNS f. GI g. hair 5.
scribe an appropriate initial the emergency depa petted of having SLE. 1435.
e two drugs that have en. Kiowa to precipitate SLE-like syndromes. efereme: (2) Harrispage 1436. 7. onstrate familiarity with the rties utilized in SLE ~~t~e~~s. rrison’s, page 1436. 8. aware of the camplicati~ ment with the above drugs. 6.
5.3.3 Scleroderma I. Identify> at the cellular level, of scleroderma. 1443. 2. List 3 life-threatening
corn lications of this dis-
ease. Reference: (2) 3. List skin and vascular disease. Reference: (2) 5.3.4 ~oIymyosiii~/ 1. Describe the 3 omyositis.
Refer~~~ce~(
riate laboratory ing the potential fo gency department . 2108.
tests ti> begin evaluat~r~os~t~sin the emer: (2) ~~~ri~~~‘s~ page
770
Marla Markham
5.4 Immunodeficiency syndromes 5.4.1 Acquired immune deficiency syndromes (AIDS)
1. Give a clinical definition of AIDS. Reference: (2) Harrison’s, page 1402. 2. List the 5 groups of persons at high risk for contracting AIDS. Reference: (2) Harrison’s, page 1403. 3. Discuss involvement of each of the listed organ systems in AIDS. Reference: (2) Harrison’s, pages 1405-7. a. central nervous system b. cardiovascular c. pulmonary d. gastrointestinal e. skin
and Glenn C. Hamilton
4. List 3 infectious diseases commonly seen in AIDS patients. Reference: (2) Harrison’s, pages 1406-7. 5. Given a patient in whom AIDS is suspected, initiate a laboratory workup. Reference: (2) Harrison’s, page 1409. 6. Be familiar with measures to prevent the spread of AIDS among health care personnel. Reference: (2) Harrison’s, page 1410. 7. What percentage of health care workers will seroconvert after exposure via needlesticks. Reference: Hamilton, page 336. 5.5 Vasculitis syndromes 1. Given 3 clinical data bases, match the correct vasculitis syndrome, including systemic necrotizing vasculitis, hypersensitivity vasculitis, giant cell arteritis. Reference: (2) Harrison’s, pages 1457-62.
REFERENCES 1. Hamilton G, Sanders A, Strange G, Trott A. Emergency medicine: an approach to clinical problem-solving. Philadelphia: WB Saunders; 1991. 2. *Wilson J, Braunwald E, Isselbacher K, et al. Harrison’sprincipies of internal medicine. 12th ed. New York: McGraw Hill; 1991.
*Indicates briefcase.
references
that are in the Internal
Medicine
3. Hedges J, Roberts J. CIinical procedures tine. 2nd ed. Philadelphia: WB Saunders; 4. Rosen P, Barker FJ II, Barkin RM, et al. concepts and clinical practice, 3rd ed. Mosby; 1991.
in emergency medi1991. Emergency medicine: St. Louis, Missouri: