INTERNAL MEDICINE IN-PATIENT ROTATION

For Family Medicine Residents

2017-18

Chief of Medicine: Dr. Michael Bonnycastle, MDCM, FRCPC

Education Coordinator: Bruce Campbell, MD, FRCPC
Revised June 2017/ Dr. B. Campbell
 Internal Medicine In-patient Rotation
For Family Medicine Residents

2017-18

St. Mary’s Hospital Centre

Chief of Medicine: Michael Bonnycastle, MDCM, FRCPC

Education Coordinator: Bruce Campbell, MD, FRCPC

Office: St. Mary’s Hospital, Office of the Chief of Medicine, room 1308
Phone: 514-734-2660

emails:
michael.bonnycastle@ssss.gouv.qc.ca
doctorcampbell@me.com
Office hours: by appointment

Administrative Technician: Caroline Mackereth

caroline.mackereth@ssss.gouv.qc.ca

Revised June 2017/ Dr. B. Campbell

Revised June 2017/ Dr. B. Campbell
PRE-REQUISITE

The physician must be a resident in one of the McGill family practice residency Programmes. Elective
residents may be considered from accredited Canadian or foreign residency programmes depending on
availability of positions on the clinical teaching unit. Residents may only be evaluated at a second year
residency level if they have successfully completed the first year rotation at St. Mary’s, or elsewhere if
approved by McGill University.

COURSE DESCRIPTION

This course is a clinical rotation designed for first and second year family medicine residents. The goal of
the rotation is to develop knowledge, skills and experience in internal medicine, in the context of family
practice, with patients in a hospital setting. The resident will spend eight weeks on a medicine clinical
teaching unit, four weeks in each the first and second post-graduate years. Two preceptors are available: a
family physician and a general internist or sub-specialist co-attending. Responsibilities include care for up
to eight hospitalized patients, five to seven overnight or evening calls per rotation, review of new cases on
the ward, and occasional internal medicine consultations in the emergency department. Other activities
include: didactic teaching, bedside teaching, participation in hospital continuing medical education, and a
formal case report and presentation. The focus of the rotation will be on patient care with an emphasis on
family medicine principles in a hospital setting. The family physician mentoring role will be extremely
important.

COURSE LEARNING OUTCOMES

At the end of the course you should be able to:

Understand and apply concepts in internal medicine to problem solving on the ward

1. Recall basic subject knowledge in internal medicine as outlined in the subject knowledge
objectives (see handout: “CTU Resident Objectives for Internal Medicine”) and available in the
recommended references and many other sources
2. Demonstrate the use of supplemental resources to improve or aid in the recall of clinical
knowledge
3. Apply this knowledge to the concepts of differential diagnosis and problem solving
4. Understand the concept of the problem-list and its importance in managing complex medical
patients

Manage patients on the ward

1. Participate in the team of students, physicians, allied health professionals and others in managing
patients
2. Organize detailed and clear documentation of patient care
3. Manage and prioritize tasks around patient care appropriately
4. Evaluate and prioritize urgent patient care at an appropriate level
5. Judge when to seek the help of attending physicians and sub-specialists
6. Understand the importance of continuity of care, admission and discharge planning during
hospitalization

Practice technical skills

1. If needed, and the opportunity arises, perform venipuncture, arterial puncture, paracentesis,
thoracentesis, bladder catheterization, nasogastric tube insertion, central venous line insertion, and
lumbar puncture, respecting the possible priority of other learners

Revised June 2017/ Dr. B. Campbell

Work in a professional manner

1. Fulfill all on-call duty requirements

2. Understand the importance of time management on a busy ward; balance ward duties and outside
responsibilities appropriately (e.g., clinic duties)
3. Relate the principles of family medicine to patient care in the hospital setting
4. Employ professional behaviour, based on the principles of family medicine, in all interactions with
patients, family members, colleagues and hospital staff.

COURSE CONTENT

The majority of learning will take place in a clinical setting similar to rotations in clinical clerkship.

To summarize the resident will spend time:

 Performing admission history and physical exams, reviewing chart information and laboratory and
imaging resources and then reviewing new cases with attending physicians in detail
 Rounding on his or her regular patients on a daily basis and preparing accompanying
documentation
 Participating in twice-weekly multidisciplinary rounds
 Meet with patients and family members on a regular basis to discuss the patients medical care
 Preparing the discharge of patients; including the hospital summary and initiating contact with
primary care physicians
 Helping to support more junior learners on the ward at an appropriate level
 Regularly fulfilling late & overnight call duties including intensive care unit coverage for second
year residents.
 Continuing to fulfill responsibilities to the family medicine residency programme, including
longitudinal clinics, and academic half-day sessions.
 Attending hospital medical education rounds weekly, and attending bedside teaching (at least four
sessions per week) and didactic rounds (see schedule provided, updated each month)
 Preparing for and presenting a “Case of the Week” (see handout)
 Preparing for and attending the oral examination in internal medicine, including a “mock oral”
presentation of a real case with the general internist or sub-specialist co-attending (see “CTU
Resident Objectives for Internal Medicine”)

COURSE MATERIALS

It should be noted that basic medical equipment is required, i.e., stethoscope, tape measure or ruler, light
source, reflex hammer, other more expensive equipment may be useful but is not required. Manual
sphygmomanometers, opthalmoscopes and otoscopes are available, as needed, on the ward.

Suggested references:

Andreoli TE, Carpenter CCJ, Griggs RC, Loscalzo J (eds): Cecil Essential of Medicine, 6th ed.
Philadelphia, W.B. Saunders Company, 2005.

Kasper DL, Braunwald E, Fauci AS, Hauser SL, et al (eds): Harrison’s Principles of Internal Medicine, 16th
ed. New York, McGraw-Hill, 2005
Swartz H: Textbook of Physical Diagnosis; History and Examination, 4th ed. Philadelphia, W.B. Saunders
Company, 2002.

A pocket, or PDA, medication reference is suggested, e.g.: the Tarascon Phamacopia (www.tarascon.com).

Revised June 2017/ Dr. B. Campbell

EVALUATION

The resident will be evaluated based on his or her ward work. This will consist of several elements:
 Participation in morning report 8h15-9h00 for all residents, including night shift.
 Attendance at Medical Grand Rounds, Thursday mornings, 8h00 am
 Assessment of participation and contribution to teaching rounds
 Written documentation in the chart
 Participation in other teaching sessions
 The “Case of the Week” presentation (see handout)
 The oral exam in internal medicine (see handout)

Resident learning will be evaluated both formatively and summatively.

Formative evaluation:

This will be done in the clinical setting. Every case discussion or brief review of patient issues with staff
and peers will be an opportunity for feedback on performance and the synthesis of new information and
experience. Attending staff will routinely give feedback to house-staff on a regular basis after case
discussions, bedside teaching and didactic teaching sessions.

Summative evaluation:

This will be in the form of the standard In-Training Evaluation Report, or ITER, familiar to residents as the
format approved by the McGill family medicine training programme for clinical rotations. This form will
summarize the evaluations of both attending physicians based on their interactions with you around patient
care and supplemental teaching over the four week period. The resident will receive an ITER after each
four week rotation; one as a first year the other as a second year resident.

A mid-rotation formal feedback session should be scheduled with both attending physicians to ensure any
potential problems are identified early and problem areas addressed. Please make sure you contact the
education coordinator if you have any concerns over the ITER.

The ITER will include evaluations from the case presentation and the oral examination in internal
medicine.

No numerical mark is given in the rotation as per the format of the ITER. Instead the resident is judged to
be:

1. Superior: if they have demonstrated this level of competency on the ITER Satisfactory: if they
are at the level of their peers on the ITER
2. Borderline: if they demonstrate multiple problem areas on the ITER
3. Unsatisfactory: if they clearly demonstrate serious problem areas on the ITER in the borderline
and unsatisfactory categories.

Borderline and Unsatisfactory evaluations are referred to the promotions committee of the family medicine
training programme.

ACADEMIC INTEGRITY

McGill University values academic integrity. Therefore all students must understand
the meaning and consequences of cheating, plagiarism and other academic offences
under the Code of Student Conduct and Disciplinary Procedures (see
www.mcgill.ca/integrity for more information).

Revised June 2017/ Dr. B. Campbell

 Department of Medicine Housestaff Team Call Responsibilities:
Coverage Policy
For Medicine Wards and ICU and CCU

Defining the new house-officer roles:

Essentially, there is a newly-designed role for an acute care resident (R2 or senior R1) who can
respond to medical calls but is not responsible for new ICU/CCU consults or Code Blues. This
new role is called the Senior House Officer.

At night, most importantly, the Senior House Officer (SHO) will respond to issues on the wards
at the request of attending physicians, or nurses when appropriate. They may or may not be
teamed up with a Junior House Officer (JHO) or medical student shadowing the night call.
Only if the Senior House Officer is an experienced resident (who has done or is doing a full ICU
rotation) they will act as a traditional ICU resident. This would encompass the SHO role and
include consults for CCU and ICU. A separate column in the call schedule will make it clear if
the ICU/CCU consult role will be covered by the SHO or the attending on ICU or a
moonlighting R4 or R5.

The family medicine program and department of medicine see the role of the Senior House
Officer as a chance to reduce some of the night-float call burden on residents while allowing
senior residents to experience managing acuity at night. This will maintain the presence of family
medicine residents in house at night in a well-defined way. The SHO should be thought of as a
rapid bedside assessor for acute issues, guided by the attendings on medicine, cardiology and
intensive care. These attendings will be available to be called at any time. Again, unless you
have done ICU, or are on the rotation currently, the ICU and CCU attendings will admit patients
and deal with ER directly. The SHO may still be called to do bedside assessments in ICU/CCU
with direct guidance by the attending.

There will be evenings and still some nights when students and junior residents will be in house.
All students and residents doing rotations in the Department of Medicine (wards, ICU, CCU) will
work together as a team during the evening and night shifts. The SHO is the team leader and will
coordinate duties and calls to attendings.

Revised June 2017/ Dr. B. Campbell

 Individual roles in detail:

EVENINGS & WEEKEND DAYS: (Sun-Thurs, until 10pm, Fri-Sat ‘til 8pm)

o The student covers the medical wards (5 South, 8 Main, 5 North, 5 Main and Off-
Service Medicine [if any on 6th floor]) as first call (except for critical medical
problems (seizures, hypotension, prolonged chest pain, etc), and calls the JHO
doing ER consults if needed.
o The JHO (usually an R1) covers Medicine consults in the ER with the Medicine
DOC, but supporting the student is their main priority. If there is no student on
that evening, the resident covers the wards. If the wards are quiet, the JHO can
be asked to see consults in ER by the DOC. The Senior House Officer may also,
if interesting, assign ICU or Cardio consults if there are no Medicine consults.
Any Medicine consults will be reviewed directly with the DOC. ICU and Cardio
consults are reviewed with the SHO.

*Exceptions when there is no JHO on call:

o If there is no JHO on that evening, the student works with the DOC in the ER. If
there is no student, consults are done directly by the DOC.
o If there is no JHO the SHO will be called for ward issues. If the SHO is called to
address a non-ICU medical matter, the SHO needs to communicate with a staff
MD for that patient. For example: it will be the ward attending MD that the SHO
will call, NOT the ICU staff MD (It is not the responsibility of the ICU staff MD
to deal with ward non-ICU issues).
o The SHO should be called for ICU matters on the wards AFTER the attending
physician has been contacted unless, at the discretion of the nurses, medical
student, or ward resident, the SHO’s presence is required urgently.

NIGHTS: (Sun-Thurs, 10pm-9am, Fri-Sat, 8pm-8am)

o The JHO will work with the SHO to cover the Medicine wards (5 South, 8 Main,
5 North, 5 Main, CCU and ICU) and off-service Medicine patients. These
residents are a team. The SHO will provide leadership and guidance to the JHO,
including reviewing cases, assigning duties and coordinating their efforts.
o For new consults: The team will take ICU and CCU consults from ER and
wards ONLY IF the SHO finds their name in the consults column on the call
schedule (this will be obvious, and paging will be aware). The SHO resident will
review cases with the JHO and call appropriate staff.
o For Admitted patients on Medicine, the SHO will decide if the staff needs to be
called, and which staff to call (i.e., individual Medicine attendings for their
patients, and ICU or Cardio attending for Critical Care patients.)

Exceptions when there is no JHO on call

o If there is no JHO on that night the SHO should be contacted. As above, if the
problem is a non-ICU matter and the SHO needs to talk to a staff MD, the SHO
should call the ward attending MD to discuss the case, NOT the ICU staff MD (it
is not the responsibility of the ICU staff MD to deal with ward non-ICU issues).
Revised June 2017/ Dr. B. Campbell
 Sign-over with an attending physician

o Sign-over with an attending physician is encouraged each morning. During the

weekday it is done in Morning Report (8:15 MTWF) or immediately before Med.
Grand Rounds (Thurs). On the weekend, the JHOs sign off to each other, as do
the SHOs. Any important issues must be brought to the attention of the attending
for that patient.

Notes for the Sr. Resident:

Weekend days:

o When the ICU staff is in house, on a Saturday, Sunday or Statutory Holiday, the
SHO can see ICU and CCU consults and discuss them with the ICU attending in
person. After the ICU staff leaves (unless they are in the consult column) they
revert to the default SHO role. (eg., ER calls the ICU staff directly)

Evenings & Nights:

o The SHO leads the Medicine team, covers acute issues on all the medical wards,
and provides support to the JHO when needed.
o If there is no JHO on call, the SHO will respond to emergencies. Again, as
above, if the problem is a non-ICU matter and the Sr. resident needs to talk to a
staff MD, the SHO should call the ward attending MD, NOT the ICU staff MD
(it is not the responsibility of the ICU staff MD to deal with ward non-ICU
issues).
o The SHO calls the ICU staff if needed for ICU-related, critical care issues
ANYWHERE in the hospital (but NOT for non-ICU/non critical care issues – in
these cases, call the patients attending MD).
o The Emergency Department physician will respond to Code Blues after 17h00.
The JHO is also encouraged to go to code blues but will not carry the code pager.
The SHO carries the call pager only if also covering ICU/CCU consults.

o Non-Medicine wards (Surgery, Ortho, Urology, Plastics OB/GYN, Psych): The

Department of Medicine does not provide first-call coverage of surgical patients
(general surgery, plastics, urology, and orthopedics patients). All calls regarding
surgical/ortho patients should be directed to the surgical house-staff or surgical
attending responsible for the patient in question. The exception is Ortho patients
already followed by Medicine. For these patients, the SHO can be called. The
SHO will contact the Medicine physician following this patient for any non-ICU
issues, and the ICU attending for obvious ICU issues.

o The Department of Medicine will continue to provide consultation services to

surgical patients once a bedside assessment has been made by a member of the
surgical staff. The Emergency Department physician will respond to Code Blues
after 1700h.

Revised June 2017/ Dr. B. Campbell

 Other issues: newly transferred patients and holding notes

o Admitted Patients: When patients are admitted to the medical units on evenings,
nights and all shifts on the weekends, the nursing staff of the admitting unit must
contact the house-staff (student or resident) according to the Medicine Night
Duty Roster to see the patient once on the ward. The house-staff is to evaluate
the patient and write a holding note with the purpose of maximizing patient
safety and ensuring continuity of care over the night.

o Off-Service Medicine Patients: Patients admitted off service on evening and

nights shifts on week days and on all three shifts on weekends will be assigned to
the admitting physician. The nursing staff of the admitting unit must contact the
house-staff (student or resident) according to the Medicine Night Duty Roster to
see the patient once on the ward and subsequently take care of any urgent
matters.

Legal and Ethical Considerations

As a student or resident you are in a position to discuss with patients their wishes with respect
to appropriate and desired treatment. This must be done with great care and sensitivity. The
timing and wording of such questions is very important and requires considerable experience
to do well. You are also in a position to raise the question as to the indications for making a
particular patient a “no code”. Everyone on the health care team, including nurses and
therapists, as well as the patient, his/her family, may raise the issue of resuscitation. The
ultimate decision rests with the staff physician in conjunction with the patient and/or his /her
family.

YOU WILL NOT BE RESPONSIBLE FOR DETERMINING OR

DOCUMENTING THE CODE STATUS OF A PATIENT.

While you are not responsible for making the actual decision, you will be expected to be
involved in the process. There is an ethics consultation service in the hospital. You are
encouraged to take advantage of this service should a clinical dilemma arise with ethical
underpinnings.

Please note that students are not legally allowed to declare patients dead. This is the
responsibility of the resident or attending physician.

Revised June 2017/ Dr. B. Campbell

 Discharge Planning For Your Patient

The care of your patients does not stop once he or she leaves the hospital. Continuity of care
is an integral part of good medical practice. Many of the patients that you will care for on the
wards have medical practitioners who provide ongoing care for the patient outside the
hospital setting.

You should inquire of every patient that you admit whether they have a primary care
physician. If they do, you should try to contact that physician to inform him/her that their
patient has been hospitalized. You can take this opportunity to expand your data base about
the patient’s medical and psychological background. This is important for treating the
patient, as well as in discharge planning. At the same time, you can assist the physician in the
care of his patient upon discharge by providing the results of investigations, as well as the
impressions of the treating team. This can be further reinforced by providing the patient with
a detailed discharge summary when he/she leaves the hospital.

You should try to be available if the patient’s physician should come to the ward seeking to
speak with you directly.

If the patient is followed at the Family Medicine Center, you are expected to contact the
treating physician, whether it is a staff member or a fellow resident. You should encourage
the physician to come to the ward and see their patient, and to coordinate with you the
ongoing care in anticipation of discharge.

Revised June 2017/ Dr. B. Campbell

 Family Medicine Resident
Oral Examination in Internal Medicine

Summary
Format

The oral exam consists of five parts:

1. The resident is asked to take a pertinent medical history and

2. perform a focused physical exam on an active, hospitalized patient who has volunteered.
3. Thereafter the resident is asked to demonstrate three further examination techniques that may not
be related to the patient’s history.
4. The resident is asked for a brief clinical summary, differential diagnosis and plan of investigation
and therapy for the patient.
5. Five questions are taken from the appropriate level of subject knowledge objectives and discussed
in detail. Traditionally, second year residents have not been asked questions from the R1
objectives, but this is not an absolute rule!

There will be one examiner observing the history taking and physical exam. Exam feedback will be given
immediately after a brief review.

The patient is a volunteer. Please treat him or her with the utmost courtesy and professionalism. The nature
of exam will be appropriate for the patient’s comfort and dignity, therefore some physical examination
techniques will be precluded in this exam (e.g., digital rectal exam), however all pertinent physical exam
techniques the resident might perform on a real patient should be mentioned to the examiner.

Time requirement

The exam will be roughly 90 minutes. 50-60 minutes for parts 1 and 2 and 30 minutes for part 3 and
feedback. Please contact your examiner early on in the rotation to arrange a convenient time. Punctuality is
important. The exam must be completed during the rotation period, usually in the fourth week of the
rotation. The resident will receive an unsatisfactory evaluation if the exam is not completed during the
rotation. Missed exams for extenuating circumstances will be dealt with on a case-by-case basis. It is not
recommended that the resident plan for time off during the rotation to study for this exam.

Learning objectives

The exam is meant to give formative feedback on history taking, physical exam and case discussion and to
provide an incentive to improve these skills. It is also a format in which subject knowledge in internal
medicine can be demonstrated, and areas for improvement can be identified.

Practice oral exam: the “mock oral”

The general internists and sub-specialist attendings on the ward will allow you to practice your “exams
personship” by watching you take a history and physical and lead you in a case discussion similar to what
is expected from the final exam. Please arrange a convenient time with them. Keep this in mind when
admitting new patients, as that is the perfect time for the “mock oral”. This will be crucial to your success
on the final exam and provide plenty of feedback as well as give you some practice.

Revised June 2017/ Dr. B. Campbell

Marking Scheme

Essentially, you will receive a satisfactory or unsatisfactory evaluation based on the following scheme:

1. History taking
2. Focused physical exam
3. Physical exam, three techniques
4. Case Discussion
5. Five subject knowledge questions depending on resident level (R1 or R2),

Each is rated satisfactory or unsatisfactory (see rubric below). The majority of sections must be satisfactory
for this to be the overall mark.

How you will be marked

See the included rubric for each section. The examiners will have the same criteria with which to evaluate
you.

Feedback

Again, this will happen immediately after the exam. You will be given a photocopy of the completed
evaluation form for the exam.

Revised June 2017/ Dr. B. Campbell

 Internal medicine oral exam for family medicine residents:
Rubric and Evaluation Form
Note: R1s are expected to perform at the level of an accomplished graduating medical student, R2s
are expected to perform standard physical examination skills and offer a differential for physical
findings
Criteria Examples
Unsatisfactory
History Taking
Introduction lacks clear introduction, does not
wash hands, little attempt to put
patient at ease
Communication Asks leading questions or does not
skills provide space for patient to give
history,
Organization lacks clear plan or direction to
history. Much time spent on
apparently non-significant details. No
follow-up of important clues. Can
still be satisfactory in this section if
pursuing an incorrect assumption in a
logical way.
Professionalism Little indication of empathy during
sensitivity the history. Potential emotionally
difficult or sensitive areas of
discussion are not recognized or are
dealt with in an insensitive manner.
Lacks common politeness or courtesy
Conclusion No clear end to the history or attempt
at summary. No opportunity for
patient to question resident.
History taking mark (based on majority of above):
Physical Examination
Positioning little attention to patient’s comfort,
safety, or appropriate position for
techniques required . Does not
explain or warn patient about how
techniques will be performed
Revised June 2017/ Dr. B. Campbell
Mark:
Satisfactory?
Satisfactory no yes
Clear introduction, washes hands, sits
at bedside, puts patient at ease, ensures
their comfort
Open ended questions to start, clarifies
things with patient, ensures quiet
environment, not distracted. Frequently
confirms story with patient and
summarizes what has been said for
confirmation
Has a clear plan for the history after
initial period. Proceeds in a logical
manner in pursuit of clues. Appropriate
attention to pertinent negatives and
positives. Shows some ability at
controlling the interview with
tangential patients
Polite, courteous and a generally
professional manner. Provides some
opportunity to explore emotional side
of illness and potential sensitive issues
are treated appropriately
Clearly indicates when history-taking is
over, provides summary and leaves
opportunity for questions from patient
(examiners may defer these for later in
interest of time)
Patient is positioned and draped
appropriately for their comfort and
safety. Patient moved in appropriate
way for different techniques. Explains
what is required to patient. Check to
see they are comfortable
Vital signs and Misses this important step Identifies need for vital signs and
general general impression
impression
Review most Misses important points on the exam, Spends most time on the details of this
important area especially crucial ones. Techniques component of the exam. Techniques are
of physical are performed incorrectly to a large performed in a acceptable way. Major
exam indicated degree. See next column for points covered.
by history examples. E.g., performs JVP if history is cardiac,
(please examines anterior lung fields in
identify): pneumonia, does appropriate lymph
_____________ node exam for malignancy, mentions
DRE in abdominal exam, etc…Should
have some idea as to significance of
findings
Next most See above See above
important
physical exam
technique by
history:
_____________
Organization Lacks clear structure to exam. Exam The exam is structured logically, e.g.,
is disorganized, no clear head and neck, chest, CVS….etc
prioritization. Too much time spent (though not necessarily in that order).
on exam techniques unrelated to Resident can justify why techniques
history. Resident cannot explain why performed or not performed. Some
most techniques performed. techniques clearly prioritized based on
history
Physical exam mark (based on majority of above):
Three unrelated examination techniques (please identify)
1.___________ Misses important points on the exam, Techniques are performed in a
especially crucial ones. Techniques acceptable way. Major points covered.
are performed incorrectly to a large
degree.
2.___________ See above See above

3.___________ See above See above

Examination techniques mark (2/3 is satisfactory):

Case Discussion
Summary Not able to summarize case at the
appropriate resident level. Summary
at odds with history obtained and
physical exam.
Differential Not able to produce a differential
Diagnosis diagnosis appropriate for their level,
or one that appears uninformed by
the case history or physical, unable to
provide justifications when
challenged
Ask for a No clear ability to organize a
Problem list problem list. Lack of awareness of
other important medical issues and
how they may relate to the main
issue
A concise and brief summary is
provided that touches on the main
points of the history. Shows some
insight into the residents confidence
with the details of the case
Able to produce an adequate
differential diagnosis related to the case
(does not need to be exhaustive). Can
give some justification to how it is
organized
Able to detail a clear problem list (does
not need to be exhaustive). Can give
justifications for its organization.
Understands how chronic issues can
complicate care of acute issue

Revised June 2017/ Dr. B. Campbell

Investigation Not able to come up with a Can offer a clear and detailed initial
Plan, use of reasonable, detailed plan of plan (e.g., as if the resident were
consultants investigation, would use consultation writing admission orders). Is there a
in a disorganized manner. Dangerous logic to how they are prioritized? If the
use of investigations is also resident is unsure of how to proceed
important to note. does he or she suggest appropriate
consult services or allied health
resources
Therapeutics Not able to suggest appropriate Able to provide a detailed, reasonable
therapy or dangerous therapeutic treatment plan for their level based on
choices without insight into lack of the outcomes of investigations stated
knowledge, or without use of above. When in doubt will consult
appropriate resources appropriate references, services and
staff.
Case discussion mark (based on majority of above):
Subject knowledge objectives (choose 5 from appropriate level of objectives)
based on “CTU Resident Objectives for Internal Medicine” (see handout)
(please list topics, answers should be noted in appropriate column in point form)
1.
_____________

2.
_____________

3.
_____________

4.
_____________

5.
_____________

Subject knowledge mark (based on majority of above):

TOTAL EXAM MARK (based on majority of 5 parts)
Please add additional comments if needed
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Revised June 2017/ Dr. B. Campbell

 CTU RESIDENT OBJECTIVES

CARDIOLOGY

Congestive Heart Failure:

RI
Can explain the reasons for the physical findings in CHF
Can identify the common precipitants of acute or worsening CHF
Can present an approach to both inpatient and outpatient treatment of CHF

R II
Can provide a definition of systolic versus diastolic dysfunction
Can explain the complications of ACE inhibitors
Understands the findings of over-diuresis in heart falure

Coronary Artery Disease:

RI
Can present a differential diagnosis of chest pain and is familiar with the common
presentations of acute coronary syndromes
Can identify and understands the rational for the essential medications prescribed post MI
Has an approach to risk factor modification

R II
Is familiar with post MI risk stratification
Understands the alterations in coronary anatomy during acute coronary syndromes
Understands the treatment options for acute myocardial infarction/ACS

Valvular heart disease:

RI
Can identify the physical findings in AS and MR
Knows the symptoms of AS
Know the etiology of the common valvulopathies: AS, AI, MR, MS, Mitral valve
prolapse

R II
Can discuss the treatment of AS and MR
Is familiar with the echocardiographic and clinical indices of severity in AS
Know the complications of prosthetic valves

Revised June 2017/ Dr. B. Campbell

Cardiac arrhythmias:

RI
Understands the indications for telemetry and Holter monitors
Has a basic approach to tachy- and bradyarrythmias
Can give a good differential diagnosis for syncope

R II
Knows the basic indications for pacemaker insertion
Is comfortable with the management of atrial fibrillation including the role of
anticoagulation and cardio version.

PULMONARY

COPD/ASTHMA

RI
Understands the difference between asthma and COPD
Can evaluate the severity of underlying lung disease
Can identify common precipitants of exacerbations
Is capable of interpreting flow rates and arterial blood gases
Understands the principles of treatment of COPD/asthma

R II
Understands the complications of steroids in COPD including myopathy
Understands the use of home oxygen and its indications
Understands the treatment of tobacco addiction

Pulmonary embolism
RI
Has an approach to the diagnosis and treatment of PE
Is comfortable with management of anticoagulation and its complications

R II
Is familiar with both congenital and acquired hypercoagulable states
Understands the indications for an inferior vena cava filter

Lung cancer

RI
Knows the basic classification of lung tumors
Is familiar with the common clinical presentations of lung cancer
Can give a differential diagnosis of hemoptysis

Revised June 2017/ Dr. B. Campbell

R II
Understands the concept of staging and knows the different modalities of obtaining tissue
diagnosis
Has a general idea of treatment modalities and prognosis in lung cancer

Pneumonia

RI
Understands the difference between community acquired and hospital acquired
pneumonias
Can identify factors indicating the severity of a pneumonia
Knows the important host factors in predicting likely pathogens in pneumonia
Is familiar with antibiotic choices in penumonia.

R II
Understands the risk factors for aspiration pneumonia and its usual location
Understands the complications of pneumonia including empyema
Can discuss the prevention of pneumonia

Pleural Effusion

RI
Can identify the physical findings of a pleural effusion
Knows the difference between a transudate and an exudate
Knows the common causes of pleural effusion

R II
Is familiar with the indication for chest tube placement
Knows the significance of pH in the pleural fluid
Can discuss the difference between bloody and non-bloody pleural effusions

RENAL

Renal Failure

RI
Understands and can differentiate between acute and chronic renal failure
Knows the common etiologies of ARF and CRF
Can differentiate between renal and pre-renal failure
Can identify the indications for urgent dialysis

R II
Understands the findings in the nephrotic syndrome and its common causes
Can discuss when a patient needs to see a nephrologist
Understands the importance and significance of the urinary sediment
Can name the common biochemical complications of ARF and CRF
Electrolyte Disturbances

RI
Revised June 2017/ Dr. B. Campbell
Understands the basic mechanisms of hyponatremia and its treatment
Understands the common causes of hypokalemia
Understands the common causes of hyperkalemia and its treatment

R II
Can give a differential diagnosis for hypercalcemia
Understands the treatment modalities for hypercalcemia and their use
Can interpret acid-base disturbances using the SMA-7 and arterial blood gas

GASTROENTEROLOGY

GI bleeds and other common GI presentations

RI
Can identify common etiologies of upper and lower GI bleeds
Has an approach to the diagnosis and treatment of H. pylori
Knows the role of endoscopy in GI bleeds

R II
Knows the common presentation for carcinoma of the colon
Understands the pathophysiology of diverticular bleeding
Has a differential diagnosis for dysphagia

Diarrhea

RI
Has a differential diagnosis for diarrhea
Can give a differential diagnosis for infectious diarrhea
Understands the biochemical complications of diarrhea

R II
Can identify some difference between ulcerative colitis and Crohn’s
Can name some extra intestinal manifestations of IBD
Has an understanding of the basic treatment of IBD

Hepatology

RI
Has an approach to abnormal LFT’s, jaundice
Can identify risk factors for viral hepatitis and describe the clinical presentation
Knows the common etiologies of cirrhosis
Is familiar with the work up of ascites

R II
Has an approach to the medical management of stones including the role of ERCP
Understands the clinical diagnosis of hepatic encephalopathy, its precipitants and
treatment
Understands the medical complications of alcoholism including alcoholic hepatitis, fatty
liver, cardiomyopathy and neurological sequelae
Revised June 2017/ Dr. B. Campbell
HEMATOLOGY

Anemia, Thrombocytopenia

RI
Can classify anemias and identify causes for each group of anemia
Has an approach to the early work up of anemia
Is comfortable with the indications for transfusion
Can give a differeneital diagnosis for thrombocytopenia

R II
Has a basic understanding of the meaning of myelodysplasia and myeloproliferation
Understands the basic management of ITP
Knows the clinical and hematological signs of hemolysis

Leukemia and Lymphoma

RI
Knows the common presenting signs and symptoms of actue leukemia
Knows the differential of a very high white count

R II
Knows the clinical features of chronic lymphocytic leukemia
Knows the common presenting features of Hodgkin’s and non-Hodgkin’s lymphoma

ENDOCRINOLOGY

Diabetes

RI
Can identify differences between type 1 and 2 diabetes
Knows the common micro and macro vascular complications of diabetes
Understands the principles and goals of treatment of type 2 diabetes
Can explain the use of short and long-acting insulins in the treatment of diabetes
Understands the difference between the various oral agents and their contraindications

R II
Can identify the usual parameters and tests used to follow a diabetic
Understands the biochemical findings in diabetic ketoacidosis and the principles of its
treatment
Understands the pathophysiology of diabetic hyperosmolar coma and its treatment. Can
explain the difference between hyperosmolor coma and diabetic ketoacidosis.

Revised June 2017/ Dr. B. Campbell

Thyroid disease

RI
Can identify the clinical and lab characteristic of hypo and hyper thyroidism
Understands the complications of hyperthyroidism

R II
Can give a differential diagnosis of a goiter including a thyroid nodule
Understands the pathophysiology of Grave’s disease

Adrenal disorders

RI
Knows that steroids should be tapered and can identify the features of adrenal
insufficiency
Knows the basic complications of steroid therapy

R II
Understands the clinical features of Cushing’s disease
Can describe the clinical presidentation of pheochromocytoma

NEUROLOGY

CVA

RI
Knows the risk factors for CVA
Understands the different approach to hemorrhage, thrombosis and hemorrhage
Can discuss prevention of recurrent CVAs including risk factor modification and anti-
platelet agents

R II
Understands the principles of thrombolysis
Can differentiate the major stroke syndromes: cortical strokes, subcortical strokes and
brainstem strokes

RHEUMATOLOGY AND IMMUNOLOGY

RI
Can list the common causes of monoarthritis and polyarthritis
Understands the risks and benefits of NSAIDS
Understands the medical and surgical approach to osteoarthritis

R II
Can explain the range of treatments available for rheumatoid arthritis
Can identify the common types of vasculitis
Has a good approach to the diagnosis and treatment of polymyalgia rheumatica and
temporal arteritis
Revised June 2017/ Dr. B. Campbell
INFECTIOUS DISEASE

Fever

RI
Has a good approach to the acute diagnosis and treatment of fever
Understands the spectrum of commonly used antibiotics
Understands the complications of antibiotics

R II
Can give a differential diagnosis for FUO
Understands the non-infectious causes of fever
Understands the issues of fever in the immunocompromised host

Tuberculosis

RI
Knows the common presentations of tuberculosis and how the diagnosis is made
Understands the utility and shortcomings of the PPD

R II
Understands the workup of those exposed to tuberculosis
Knows the common medications used in the treatment of tuberculosis

AIDS

RI
Understands the etiology and pathophysiology of HIV infection
Can describe the common presentations of HIV infection and its complications

R II
Can explain the concept of viral load and its significance
Understands the general concepts of prophylaxis and antiretroviral therapy in AIDS
patients.

Revised June 2017/ Dr. B. Campbell