Department of Internal Medicine - Educational Programs
M3 Rheumatology Outpatient Rotation
Your M3 teaching in the Rheumatology Clinic represents a wonderful opportunity to further develop your skills at taking a systematic history, performing a physical examination, evaluating appropriate laboratory information and synthesizing a therapeutic plan tailored to the individual patient. Because rheumatology so frequently spans multiple organ systems it is an ideal setting to be exposed to the breadth and challenges of Internal Medicine.
EDUCATIONAL GOALS:
- To gain exposure to outpatient Adult Rheumatology
- To be introduced to the clinical assessment of musculoskeletal problems
- To review your lecture notes from the Rheumatology FCP IV core
- To review the Screening Musculoskeletal Examination booklet, exam check list and practice the screening and general musculoskeletal exam
- To perform a history and physical examination on 1-2 outpatients with musculoskeletal problems each week
- To prepare a well organized patient write up/progress note on one patient per 1/2 day clinic (due on the following day)
- To establish a framework for thinking about musculoskeletal problems in the context of general Internal Medicine
- To be introduced to specific aspects of the rheumatologic history and physical examination as part of essential skills for the practice of general Internal Medicine
REQUIRED READING:
Before First Session:
- Review your rheumatology FCP IV core lecture notes
- Review Screening Musculoskeletal Examination booklet, exam checklist and practice the screening musculoskeletal examination
- Read Chapter 2 "Clinical Manifestations of Rheumatic Disease" from R. Bluestone, Practical Rheumatology: Diagnosis and Management, Addison-Wesley (1980) (Enclosed in your packet we sent to you via campus mail)
During 3-4 Week Rotation:
- Read chapters pertinent to patients seen in clinic and chapters 7 and 8 in the Primer on the Rheumatic Diseases, 12th Edition, Arthritis Foundation, 2001
Last year's M3 students found this to be a fun and rewarding rotation, and we hope you will feel the same way!
RHEUMATOLOGY OUTPATIENT CLINIC:
During our 3-4 weeks together, you will be assigned ~2 patients per 1/2 day clinic. These patients will either be new or return patients. It would be best if you can arrive in the rheumatology clinic a few minutes early (just before 8:00 or before 1:00) to identify patients marked "M3" for you to see. This will provide an opportunity to review the patient's recent clinic notes.
For NEW patients, please perform a complete history, a general physical examination and a screening musculoskeletal exam; this should take approximately 45-60 minutes.
For RETURN patients, you should perform a problem oriented history, a limited general examination (as appropriate to the problem at hand) and a screening musculoskeletal examination; this should take approximately 30 minutes.
Note: It is impossible to accurately assess the musculoskeletal system with the patient's clothes on. For this reason, you should be examining virtually all patients unclothed (in underwear and gown) regardless of whether they are new or returns.
Next, you should succinctly (5 minutes or less) present the case to your attending. We will then discuss the patient's problem(s) and see the patient together, reviewing aspects of the history, physical examination and the clinical approach to diagnosis and management. Note: Some staff will ask you to present in front of the patient.
RHEUMATOLOGY THURSDAY CONFERENCE (Thursday discussion):
Our small group session together on Thursday afternoon will provide a chance for us to discuss and clarify essential concepts of the history, physical examination and evaluation of patients with rheumatic diseases. Thursday Conference is held from 2:30 - 3:30 in Rm C315, the first three Thursdays of your one month rotation
The theme for the 3 conferences is "The Approach to the Patient with Musculoskeletal Complaints." Material to be covered will include the evaluation of patients with joint complaints (articular joint disease), regional or generalized pain syndromes (soft tissue rheumatism), and systemic rheumatic diseases (e.g. SLE, Inflammatory Muscle diseases, scleroderma). The required reading in chapters 7 and 8 of the Primer on the Rheumatic Diseases will supplement these discussions. Material in the text and conferences may not correspond temporally.
Reading for:
- Week 1: Evaluation of monarticular and polyarticular joint disease (pg 157-165, 138-43)
- Week 2: Evaluation of disorders of the low back and neck (pg. 165-173)
- Week 3: Evaluation of regional and generalized pain syndromes (pg. 174-193)
Learning Obectives:
- Recognize common arthritic complaints
- Develop an approach to the evaluation of monarthritis
- Describe at least 3 causes of monarthritis
- Develop an approach to the evaluation of polyarthritis
- Describe at least 3 causes of polyarthritis
- Recognize the parameters that distinguish inflammatory from non-inflammatory back and neck pain
- Recognize common regional and generalized pain syndromes
- Develop an approach to the evaluation and treatment of these disorders
- Recognize the common systemic rheumatic diseases
- Develop an approach for their evaluation
NEW PATIENT / RETURN PATIENT WRITE UPS (M3)
NEW PATIENTS
CHIEF COMPLAINT, REASON FOR VISIT / CONSULT:
why is the patient here now? what questions does the referring physician want answered?
HISTORY OF PRESENT ILLNESS:
chronology of present illness including important background information, previous outside information [prior examinations, lab work and treatment (for rheumatologic medications include dose, duration and response)] in sequential fashion with appropriate rheumatologic review of systems incorporated into end of HPI.
PMH, SH, FH, (REVIEW OF SYSTEMS):
RETURN PATIENTS
INTRODUCTION:
1-2 sentence "bullet" which succinctly establishes the context
INTERVAL HISTORY:
"bullet" re: last visit (complaints/problems, exam/abnormalities, labs, treatment & response) and interval history to present visit plus pertinent review of systems as indicated.
ALL PATIENTS
MEDICATION LIST:
PHYSICAL EXAMINATION:
complete physical examination (new) or focused exam (return)
plus screening musculoskeletal examination (stressing abnormality: deformity, visible swelling, altered range of motion, muscle atrophy and gait)
LABORATORY:
IMPRESSION/PLAN:
problem list followed by paragraph of discussion where you reveal your synthesis and therapeutic plans
These write ups should be completed and turned into your attending staff no later than the following day. Your write ups will be reviewed and returned to you with appropriate helpful comments.
revised 6/27/05 |
