Department of Internal Medicine - Division of Immunology
Orientation For Rotating Residents
and Medical Students
Introduction
During the next four weeks you will have an intensive exposure to outpatient Rheumatology. At the end of this time we hope that through your patient contact, didactic sessions and diligent self-study you will be better able to:
Educational Content and Goals
The goal of the rheumatology elective is to provide experience in the recognition, evaluation and management of musculoskeletal problems.
Attitudes
Clinical effectiveness in treating patients with rheumatic diseases depends upon an understanding of how chronic illness can effect nearly every dimension of a patients life. Exposure to a wide breadth of rheumatologic problems (especially in the ambulatory setting) can contribute substantially to the development of an attitude of compassion, sensitivity and understanding of patients with chronic diseases. It is hoped, as well, that this elective will help to clarify frequent misunderstandings about rheumatology and musculoskeletal problems, replacing all-too-common attitudes of fear or inadequacy with confidence in approaching such patients. Your subsequent exposure to patients on the wards as well as in your COC clinics will provide a wonderful opportunity to continue your growth in understanding and management of rheumatologic problems.
Skills
Understand key elements of the rheumatologic history, activities of daily living and rheumatologic review of systems critical to the diagnosis of rheumatologic problems. Develop skill and demonstrate proficiency at performing a complete musculoskeletal examination (to include capability for detailed assessment of the upper extremities, lower extremities and spine). Understand the appropriate use of the laboratory in the diagnosis and management of rheumatic diseases.
Knowledge base
Exposure to common forms of:
Specific learning goals for these disorders are outlined in the Educational Goals for Rotating Residents and Medical Students that you will receive. The Educational Goals are designed to encourage and augment self study during this rotation, while studying for exams or later in practice. A bibliography of important articles has also been provided for you to refer to now and in the future. Copies of these articles are available in the Rheumatology library and in the Internal Medicine Chief Residents' office.
Intellectual curiosity
Clinical exposure in the outpatient setting combined with appropriate conferences and reading will all contribute to fostering intellectual growth and facilitate life-long learning habits.
Resident Required Reading List:
The following reading selections are taken from the Primer on the Rheumatic Diseases (10th Edition) Copyright 1993. This reading list constitutes the minimum reading requirement for this 4 week elective.
General Principles
Chapter 2: The musculoskeletal system
Chapter 8: Evaluation of the patient
Periarticualr Problems/Soft Tissue Rheumatism
Chapter 50: Regional rheumatic pain syndromes
Chapter 41: Fibromyalgia syndrome
Articular Problems/Arthritis
Chapter 24: Osteoarthritis
Chapter 31: Gout
Chapter 32: CPPD
Chapter 33: Apatites (Basic Calcium Phosphate) & Misc.
Chapter 10: Rheumatoid arthritis
Chapter 20: Seronegative spondyloarthropathies
Chapter 26: Infectious arthritis
Chapter 27: Lyme disease
Extra-Articular Processes/ Systemic Connective Tissue Diseases
Chapter 15: Sjogren's syndrome
Chapter 11: Systemic lupus erythematosus
Chapter 12: Antiphosholipid syndrome
Chapter 13: Systemic sclerosis and related syndromes
Chapter 14: Inflammatory and metabolic myopathies
Chapter 16: Undifferentiated connective tissue synfromes
Chapter 17: Vasculitis
Chapter 18: Polymyalgia rheumatica
Bone
Chapter 48: Osteonecrosis
Chapter 49: Paget's disease
Chapter 45: Hypertrophic osteoarthropathy
Chapter 52: Metabolic bone diseases
Nerve/ Neuropathy
Chapter 47: Disorders of the back and neck
Chapter 25: Neuroarthropathy
Regional MS Problems
Chapter 54: Sports and occupational injuries
Therapeutics
Chapter 55: Nonsteroidal drugs
Chapter 56: Slow acting anti-rheumatic drugs and cytotoxics
Chapter 59: Surgical treatment of arthritis
Chapter 60: Rehabilitation of patients with rheumatic diseases
Chapter 61: Psychosocial factors and arthritis
The following reading selections are taken from the Primer on the Rheumatic Diseases (10th Edition) Copyright 1993. This reading list constitutes the minimum reading requirement for this 4 week elective.
General Principles
Chapter 2: The musculoskeletal system
Chapter 8: Evaluation of the patient
Periarticular Problems/ Soft Tissue Rheumatism
Chapter 50: Regional rheumatic pain syndromes
Chapter 41: Fibromyalgia syndrome
Articular Problems/ Arthritis
Chapter 24: Osteoarthritis
Chapter 31: Gout
Chapter 32: CPPD
Chapter 10: Rheumatoid arthritis
Chapter 20: Seronegative spondyloarthropathies
Chapter 26: Infectious arthritis
Chapter 27: Lyme disease
Extra-Articular Processes/ Systemic Connective Tissue Diseases
Chapter 15: Sjogren's syndrome
Chapter 11: Systemic lupus erythematosus
Chapter 17: Vasculitis
Chapter 18: Polymyalgia rheumatica
Bone
Chapter 52: Metabolic bone diseases
Nerve/Neuropathy
Chapter 47: Disorders of the back and neck
Regional MS Problems
Chapter 54: Sports and occupational injuries
Therapeutics
Chapter 55: Nonsteroidal drugs
Chapter 56: Slow acting anti-rheumatic drugs and cytotoxics
Chapter 59: Surgical treatment of arthritis
Chapter 60: Rehabilitation of patients with rheumatic diseases
Chapter 61: Psychosocial factors and arthritis
Rheumatology Clinics:
UIHC Clinic:
The majority of your time will be spent at the UIHC rheumatology outpatient clinic, located in Orthopaedics area of Lower Level JPP.
Clinic days:
You are expected to attend the outpatient clinic on Monday mornings, Tuesday mornings and afternoons, Wednesday mornings and afternoons, Thursday afternoons and Friday mornings and afternoons. Morning clinics begin at 0800 and afternoon clinics begin at 1300 (except on Thursdays when clinics start at 1400). Clinics end after all patients have been seen and staffed.
Residents
Please inform us of your COC days. You are not expected to be in Rheumatology Clinic on your assigned 1/2 day COC's.
Patients:
Physicians in our clinics provide continuity of care and have continuing responsibility for their own patients. Patients are listed on the blackboard each day along with their scheduled time of arrival and the attending staff's name. You "sign up" for a patient by placing your name or initials in the column to the right of the patient's name. This allows those in the clinic to know that a particular patient is being seen and by whom.
You should sign up for patients in the order in which they arrive, giving preference to the patients with the earliest scheduled appointment time. When possible, sign up for a new patient to increase your exposure to fresh diagnostic problems. New consultations being seen by the Consultation Service are generally worked up by the consult resident or fellow (and not M4's).
Prior to introducing yourself to the patient, you should spend no more than 10 minutes for a return or 15 minutes for a new patient reviewing recent clinic notes or outside records which may accompany the patient. If you anticipate the need for a longer delay, please introduce yourself to the patient, and explain what you intend to do (it puts the patient at ease, reduces their frustration and will generally enhance cooperation when you begin your history and examination). When you are ready, please ask a nursing assistant to place your patient in an available examination room (if they are not already in a room). The nursing assistant will then list the exam room number on the blackboard next to the patients name and you can proceed.
Patient workups:
For new patients, perform a comprehensive history and physical examination. This should generally require no longer than an hour from start to finish. For return patients, perform a problem-oriented interval history (after obtaining a concise grasp of the underlying problem and its presentation), a general examination (as appropriate to the problem(s)) and a complete musculoskeletal examination. You should generally take no longer than 30-40 minutes for the history and physical examination on these return patients.
Note:
Failure to visualize musculoskeletal structures during the physical examination is the most common error made by examiners at all levels of training. 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 a gown) regardless of whether they are new or returns.
Presentation:
Next present the patient to the staff physician. The staff physician will accompany you back to the exam room to expand on / reconfirm selected aspects of your evaluation and refine the therapeutic plan.
Ordering labs / procedures:
Please stamp (or hand write) the patients name on any test requests (include the staff's CLP # on all labs ordered) and give this information with the green patient addressograph card to the clinic staff at the front desk. Do NOT give lab, X-ray or other slips directly to the patient.
Waiting to staff:
If you anticipate an excessive time before you can staff this patient with the faculty, please tell the patient of the anticipated delay (this courtesy is greatly appreciated by our patients).
If patients are waiting (and rooms are available) please begin to evaluate another patient and inform that next patient that you will be called away during history and physical to staff your first patient once the faculty becomes available. Please notify your attending if you enter a second room before staffing your first patient (so they may get you once they are available to staff).
VA CLINIC
VA outpatient clinic (1st floor adjacent to emergency room)
Clinic days:
Thursday mornings at 0800
Patients:
Both new consults and return patients are seen in the Thursday AM rheumatology clinic and may be worked up by any trainee.
Patient workups:
General format for working up new and return patients is similar to UIHC clinics.
Presentation:
Similar format to UIHC clinics
Ordering labs / procedures:
Lab work may be ordered by writing desired studies directly on the bottom of the progress note sheet and presenting this to one of the clinic nurses in the intake area so that necessary blood may be drawn, etc. Additional questions regarding other studies should be directed to the clinic nurses to be certain we are using appropriate forms and following necessary VA procedures.
Waiting to staff:
Similar procedure to UIHC clinics.
Consultation Service
During your month on Rheumatology, you will be assigned to a block of time on the consultation service (10-14 days, depending on the total number of residents on the service at that time). You will work closely with your Rheumatology staff attending and the first year rheumatology fellow (2 weeks / month) or with the Rheumatology staff attending alone (2 weeks / month). One M4 student will also be assigned to the consultation service (for 10 days) and will work up patients and round with you and the team. During this time, your primary responsibility will be to the consult service (working up patients, doing patient-related literature searches, making rounds with the team, etc).
When you are not occupied in this way, you will still be expected to see new and return patients in Rheumatology clinic. Please be sure to check with the consult attending (and / or staff in clinics) before leaving the Rheumatology Clinic to pursue these activities to be certain no manpower shortage will result in the clinic.
Clinical Research Studies:
Please be aware that the Division of Immunology has several ongoing clinical research studies. Please contact Dr. Ken Saag if you are seeing any patient who is involved in, or may be eligible for participation
in one of our studies (this includes evenings, nights and weekends)
Patient Write Ups:
UIHC: Several preprinted worksheets are available in the clinic which are helpful in note taking and recording the musculoskeletal physical examination.
Residents:
Please dictate your patient care letter following your encounter (if no patients are waiting to be seen) or later in the day. Please keep all letters as succinct and pithy as possible. Avoid conversational styles and ÒfillerÓ phrases.
Students
Each day, we would like you to select ONE of the patients you saw (either a new or return patient) and submit a well organized, thoughtful new / return patient write up [including the important aspects of staff-confirmed PE findings and discussion with you] This write up should be written on progress note paper (no more than 2 sides), with particular emphasis on your impression and plan, and turned into the attending staff no later than the following day. These write ups will be reviewed and returned to you with appropriate helpful comments. Your worksheets / written notes on the other patients you saw that day should be legible and accurately recorded (and may help your staff attending with the dictated letter).
New Patient/ Return Patient Write Ups
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) 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 (return patients):
"bullet" re: last visit (complaints, exam, labs and treatment) 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 examination plus complete musculoskeletal examination (stressing abnormality: deformity, change in range of motion, swelling)
Laboratory
Problem List
differential diagnosis, appropriate discussion and final synthesis for each problem.
Plan:
therapeutic plans and follow up.
VA Clinic
A standardized progress note form has been developed for use at the VA clinic. Although it is imperfect in many ways, it provides a fairly uniform follow up sheet for rheumatology clinic patients. It may be necessary (and desirable) to add a second standard progress note sheet to permit more detailed recording of your impression and plan for new consults seen in the rheumatology clinic. All notes must be completed and counter signed by attending staff during clinic.
Conferences, Lectures, and Small Groups
Complete musculoskeletal exam:
Rheumatology Core Conference:
Rheumatology Case Conference:
Radiology conference:
Teaching sessions in rheumatology are generally held in the rheumatology library (located in the rheumatology division offices on the 6th floor, SE general hospital (SE634, GH). Radiology conference (valuable review of bone and joint radiographs) is held in the MRI reading room, located in the basement of Colloton Pavilion (take the elevator to the basement and follow signs to MRI reading room).
Evaluation of Knowledge Base
To further guide your learning, you will also receive a self-test that covers the same material and concepts as outlined in the Educational Goals. You must complete the test and have answered at least 70% correctly to pass the rotation. You can complete the test at your own pace and use whatever references you like. The test will not be a part of your evaluation and all questions relate directly to the Educational Goals.
Evaluation of Rotation
The rheumatology division will supply each resident with a written evaluation form detailing various aspects of the rotation and teaching by the rheumatology faculty. We value your input very much and will utilize constructive criticism to improve our rotation.