College of Medicine

Inpatient Internal Medicine-Pediatrics PACE Subcommittee

Maria Cannarozzi, M.D.

December 16, 2004

USF College of Medicine

Internal Medicine-Pediatrics PACE Subcommittee

Maria Cannarozzi, M.D.

Objectives

• ““Disease in the context of a lifetime”Disease in the context of a lifetime”

• Incorporate ILC topics via innovative Incorporate ILC topics via innovative learning experienceslearning experiences

• Emphasize pathophysiology common Emphasize pathophysiology common to both pediatrics and adult medicineto both pediatrics and adult medicine

• Unify two clerkshipsUnify two clerkships

• Preserve mutual exclusivityPreserve mutual exclusivity

Sir William Oslerhttp://www.medicalarchives.jhmi.edu/sgml/osler.html

Components

• Nonintegrated vs Integrated

• Weekly themes

• Conferences

• Integrated longitudinal curriculum

Clerkship Curriculum

• Nonintegrated– Patient encounters and

ward experience

– Case based conference

• Integrated– Keynote conference

– ILC

– Clinical modules

– ECG lecture series

Weekly Themes

1 Cardiology – congestive heart failure/cardiac dyspnea

2 Pulmonary medicine – obstructive lung disease/respiratory failure

3 Endocrinology – diabetic ketoacidosis/HHNK physiology

4 Infectious Disease – sepsis/presentations of infection

5 Rheumatology – inflammatory joint pain/SLE/vasculitis

6 Gastroenterology – acute abdomen

7 Nephrology – acute renal failure/fluids and electrolytes

8 Hematology/Oncology – anemias/common malignancies

Conferences

• Keynote

• Case Based Conference

• ECG

Integrated Longitudinal CurriculumWeekly Task

-- Management issues of a simulated case of a sickle cell patient in aplastic crisis who follows the religion of Jehovah’s witness

-- Plan a vaccination strategy for influenza season with a limited supply

-- Managing the care of a patient with a newly diagnosed terminal illness –“breaking the news”

-- Management of a cancer patient with uncontrolled pain-- Attending Tumor Board and presenting a patient/treatment plan-- Spending time in the ER reviewing criteria for admissions for

various/specific diagnoses

-- Spending a day working with nutrition services, specifically what is involved in preparation of various patient diets, including the formulation of TPN

-- Spend a day in hospital administration/hospital operations management in order to appreciate and become sensitive to issues related to administrative aspects of inpatient medical care

Sample Week 2: Pulmonary

Mon Tues Wed Thur Fri

ILC Weekly Task

CBC Noon Report CBC Keynote conference

ILC discussion

ECG lecture

Quiz/review

Student forum

Weekly On Line Module

Student Portfolio

A closer look…

Electronic Portfolio

STUDENT LOGBOOK – PATIENT DATA/PROCEDURES DOCUMENTATION OF WEB-BASED MODULE COMPLETION  DOCUMENTION OF ILC TASK COMPLETION  FACULTY AND RESIDENT PHYSICIAN EVALUATIONS  WEEKLY QUIZ SCORES  COMPREHENSIVE WRITTEN EXAMINATION SCORE

CLINICAL PERFORMANCE EXAMINATION SCORES

Inpatient Internal Medicine-Pediatrics On Line Curriculum

Weekly Task

Keynote Conference

Clinical Modules

Assessment

• Ward evaluations from attending and residents• Weekly quizzes • ILC task completion• Module completion • ECG competency exam• Student log (diagnoses and procedures)

completion• Comprehensive written exam• Case-based clinical performance examination

Further Considerations

• Eight weeks continuous ward service– Workload demands and time restraints– Ward team responsibilities vs independent

learning

• Balancing didactic education and clinical experience

• Continual curriculum assessment and improvement

ILC Weekly Task

Sir William Osler

http://www.medicalarchives.jhmi.edu/osler/oslerroom.htm

Sir William Osler

http://www.medicalarchives.jhmi.edu/osler/oslerroom.htm

“Follow the antibiotic” Starting with the order entered by a physician, physically track the process of an IV antibiotic or

blood product being administered. Identify and record the following items (do not allow your presence to influence the people you are observing):

The name and role of every person who reads the order, or touches the medication/blood product

The manner in which the medication/blood product is prepared and storedHow the order and medication/blood product are verified to matchHow the medication/blood product is transported to the wardThe name and role of everyone on the ward who processes or delivers the

medication/blood product to the person who administers itThe supplies needed to administer the medication/blood product to the patientThe verification process for ensuring the medication/blood product given to the patient is

correctThe manner in which the medication/blood product is administered including equipment,

rates, and site of entryAny counseling or information the patient/patient’s relative received by anyone involved in

the entire process regarding the medication/blood productThe time for the entire process to occurWhat benefit/drawbacks does the patient/patient’s relative expect from the

medication/blood product

Sir William Osler

http://www.medicalarchives.jhmi.edu/osler/oslerroom.htm

Answer the following questions:

Identify 10 possible moments at which unintended error may occur

What information do you think should be provided to the patient or their relative regarding the administration of the medication/blood product (be specific)?

What is the manufacturer’s listed cost of the medication/blood product? How much does the hospital pay for it?

USF HEALTH SCIENCES CENTER

Keynote Conference Agenda for Week 2: Pulmonary

medicine

Representative Faculty:

 Pulmonologist, general internist, general pediatrician, basic sciences physiologist,

pharmacologist

Keynote Conference Agenda for Week 2: Pulmonary medicine

Topic: Obstructive pulmonary disease – asthma/COPD

 Objectives:  Discuss pathophysiology of obstructive lung disease,

including anatomic features, etiologies, risk factors, clinical presentations and management.

 Discuss how these physiologic processes differ in the

adult and pediatric population i.e. bronchospastic hyperreactive airways vs. structural changes caused by environmental toxins (cigarette smoke) or congenital disorders (cystic fibrosis).

 Discuss how patients of varying ages might present.  Discuss management strategies for patients of

varying ages and why these strategies might differ.

Topic: Respiratory failure in the child and adult Objectives: Discuss primary pathologic mechanisms of respiratory

failure i.e. hypoxia and hypoventilation – how these might occur and which are more prevalent in pediatric vs. adult populations

 Discuss presentation of respiratory failure i.e. warning

signs, different age presentations Discuss the detailed pathophysiology of a selected type

of respiratory failure: i.e. hypoxia secondary to diffusion abnormality. Why does this occur in the pediatric vs. adult patient? How do we treat it?

 Discuss age-appropriate management strategies for

selected respiratory disorders.

Pulmonary Function Test

• Spirometry– Slow maneuvers

– Forced maximal maneuvers

• Lung Volumes– Plethysmography

– Inert gas washout/dilution

– Planimetry

• Diffusion Capacity

• Pulmonary Mechanics– NIP, MVV, MEP

Case # 3

• A 72-year-old woman with long standing tobacco use (150 pack years) undergoes PFT testing for evaluation of increasing dyspnea.

Spirometry Results

Meas Ref %Pred

FVC 3.66 4.39 83

FEV1 1.03 2.87 36

FEV1/FVC 28 65

FEF25-75 0.33 2.48 13

PEF 4.29 8.33 52

                                                                 

Flow volume loop Effort loop

Severely blunted exp

curveBoth are smooth in

contour

Pronounced air trapping with lung fields below breast shadows

Question

• What is the most likely diagnosis?1. Asthma

2. Asbestosis

3. Neuromuscular weakness

4. COPD