Internal Medicine Clerkship: Learning from Patients - … · ROSS UNIVERSITY SCHOOL OF MEDICINE...

ROSS UNIVERSITY SCHOOL OF MEDICINE

Internal Medicine Clerkship: Learning from Patients

Vijay Rajput, MD,FACP,SFHMProfessor & Chairman of Medicine

Associate Dean, Academic & Student AffairsRoss University School of Medicine

2300 S.W 145 Avenue, Suite 200Miramar, FL 33027

Phone: 754-208-4742

Email: [email protected]


Contact Information

Department Chair: Vijay Rajput, MD, FACP, SFHM Professor of Medicine, RUSM Department of Medicine Email: [email protected]

Clerkship Director: Dr. Vedi Patel, MDEmail: [email protected] W. 19th Street, Chicago, IL 60627


Contact InformationMy cell phone: (609 )560‐6009

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Learning objectives for this session

• How to study during the clerkship for NBME subject and CK, CS examination?

• How to think about the career in medicine?• How to Navigate IM clerkship successfully?


Three Key things to do for your patients every day

• Listen to your patients

• Take Care of your patients

• Go extra mile (even few steps) for your patients


Overview of the Inpatient Clinical Experience

• 12 Total weeks will be spent on the inpatient and part of it as outpatient service

• On‐Call experience

• Study time

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How will you divide your time?

Now ( bedside and classroom, rounds)

Near ( NBME shelf exams(

Far ( USMLE CK and CS)


Time Management

• Use short chunks of time to study • Don’t wait to find 2‐3 hours together• Study during “downtime” or “waiting”• “Robbing Peter to pay Paul” • Skipping a class for final or paper is a trap


Some Controversy – or Student Dependent ? • Class vs. Skipping class (teaching self)

• Books vs. No books

• Notes vs. No notes

• Individual vs. Group

• Practice questions vs. No practice questions


How to Manage High Volume Knowledge

• Find the “Big picture” – in lecture or bedside • Annotating lecture slides and notes• Create summary charts or notes for memorization

• Actively memorize• Practice application


Depth and Breadth

Depth of knowledge

Breadth of Knowledge


How to actively learn the material?• Don't wait to memorize just before exams• Memorize the heading • Memorize the knowledge with short phrase or key words

• Save picky materials night before the exams • Quizzing each other• Frequently review the material

•Practice‐Practice‐Perform


How Do I Prepare for Exams?

• Clarify concepts, definitions, context• Familiarity of material – Oh that makes sense! • Mastery of material – requires integration and memorization of material – allow application to new situations

• Understand multiple steps needed for complex questions


Three Types of Reading Everyday

• Read about your patient diseases and conditions from text book, review article from journal like NEJM, Annals, BMJ, Lancet

• Read the IM Essentials text and questions for NBME shelf examination

• Read about the assignment given on the rounds


Your Education is YOUR Responsibility

Accountability

Trust

Autonomy


Expectations & Responsibilities

① Be punctual for all clinical and academic activities

② Dress professionally:• White coats• No open‐toed shoes• Dress shirts, ties, and dress slacks for men• Professional blouse, skirt/slacks for women

③ Be in possession of all required medical equipment

④ Promptly respond to pages, phone calls, and emails

⑤ Act in a professional manner at all times

⑥ Submit all required documentation in a timely fashion (H&Ps, Mini‐CEX forms, case logs) 16


EXPECTATIONS & RESPONSIBILITIES

⑥ Actively participate in clinical care:• Provide care for 2‐3 established patients daily

o Pre‐roundo Present their case on teaching rounds in a SOAP formato Write a daily progress note using the inpatient SOAP templateo Assist the team in their medical managemento Participate in safe and effective transitions of care at both “sign‐in” and “sign‐out”

• Admit at least one new patient during both early and late admitting days:• Perform the initial evaluation (history, physical examination, development of plan)• Present the patient to the teaching attending• Write the initial encounter H&P using the inpatient template

⑦ Actively contribute in all educational activities

⑧ Complete all required educational assignments in a timely manner:• Mini‐CEX exercises• Assigned weekly reading as RUSM curriculum

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Team Structure

• Teaching service teams • Teaching attending ( Hospitalist or specialist)• Senior resident (PGY‐2/PGY‐3)• one or two Intern (PGY‐1)• 1‐2 Third‐year medical students• +/‐ Fourth‐year subintern

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General Principles for Case Presentation

• Think of yourself like a lawyer pleading a case. Your entire presentation should be dedicated to building a case, not for a client, but for a differential diagnosis.

• Plan to talk for no more than 2‐4 minutes. The discussion may end up taking longer but your presentation should be brief and concise.– Include only the most essential facts but be prepared to answer any question.

• Adhere to basic format. – Chief complaint– History of present illness (Progression, Quality, Region, Severity, Timing)– Most review of systems is incorporated at the end of the History– PMH, PSH, Fhx– Allergies, medications ( current, home and OTC)– Vitals, Physical examination ( focused system based, with key positive and

pertinent negative)– Laboratory, radiographic findings– Assessment and plan ( clinical reasoning)


General Principles for Case Presentation

• Do not skip sections.• Don’t forget home medications.• Try to tell a story. It’s often easiest to go chronologically after you

give the opening statement. Do not read the presentation.• Keep it lively and expect interaction from the team with questions.• Always give vitals. Don’t say “vital signs stable.” • Ask your attending how they want labs presented. Most will want

just abnormal labs.• Avoid giving commentary on the vitals, physical exam, etc. until

you get to the Assessment and Plan section.• In Assessment and Plan, give one‐line summary of presentation

with most salient features. Don’t recap the entire presentation.


Case Presentation Tips• Be aware of your posture.• Maintain eye contact ‐ glance at your notes only as necessary.• Present with a clear, energetic, and interested voice. You have become a

"storyteller", and are giving information of crucial importance in the life and care of another human being.

• Follow the outline of the OCP in a linear fashion ‐ do not skip around.• Keep your language precise.• Use positive statements rather than negative statements: "Chest Xray

shows normal heart size" is better that "chest X ray shows no cardiomegaly". "In summary, this patient's problem is acute dyspnea" is better that "the patient's problem is rule‐out pneumonia".

• Do not rationalize or editorialize as you present, just tell the "facts" as they were obtained by you. Remember, you are telling the patient's story, not your own. Example: at the end of the History of the Present Illness, you would not say: "I would have gathered more information, but the patient's breakfast came and the nurse kept interrupting to change the patient's dressing, administer medications, and check vital signs."

https://catalyst.uw.edu/workspace/medsp/30311/202905


Resources:

• The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)http://meded.ucsd.edu/clinicalmed/oral.htm

• https://fd4me.osu.edu/lp‐preceptors/system/block_resource_items/resources/000/000/048/original/Oral_Presentations_handout.

• Yurchak PM. A guide to medical case presentations. Resident Staff Physician. 27:109‐115 (1981)

• https://catalyst.uw.edu/workspace/medsp/30311/202905

• Le T, Bhushan V, Amin C. First Aid for the Wards: Insider Advice for the Clinical Years. (Stamford CT: Appleton & Lange, 1998)

•


Nurses can be your Best Friend….or your Worst Enemy

• Learn from them• Be nice to them • Talk to them before you see your patient• You are one team• They don’t work under you !!!!!


Learn from Everyone

• Talk to near peers in that speciltity ( residents and fellows, Junior faculty)

• Talk to senior physicians in that field ( both academia and private practice)

• Talk to non‐physicians in that field ( NPs, PAs, Nurses in OR, hospital floor, office managers)


Week 1


Week 6


Mid Clerkship Formative Assessment

• Take appointment with your site CD for mid term formative assessment

• Bring your case logs, Med U Sample cases and all MiniCex completed by your faculty and residents

• Tell CD about how is your clerkship going –good, bad and ugly !


Learning tools for students with clinical team • Ask teaching questions• Think aloud• Prepare next task from patient care• Recognize teachable moments• Identify knowledge gaps as team• Say “ I don’t know” at least once a day• Frame concepts around patient care


ASSESSMENT PROCESS

• Assessment is formative and summative in nature.

• Students will receive a composite evaluation of their clinical performance at the end rotation .

• Students are expected to have the assigned teaching attending physician and/or senior resident complete at least 6 Mini‐CEX assessment form in each of the following domains:

o Medical interviewingo Physical examinationo Case presentationo Written documentation (to be completed by clerkship director)

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MiniCex ( direct observation assessment tool) • MiniCex: These are direct

observation of students by faculty during the IM clerkship. The students are required to complete at least six of them during their clerkship. They will be on portal or hard copy student can carry during the clerkship. They should bring the MiniCex for review during the midterm assessment by site clerkship director.



PICO exercise

• Goal:Medline citations do not treat patients –clinicians do. It seems there is still a gap between the idealized, ambitious aims of EBM and the realities of practice.

• We want student to learn the ideas of information “pull” in steps of EBM and apply on patient care.

• This will help them in their problem based learning and develop life‐long learning skills in acquiring new knowledge for their clinical practice.


PICO during the IM clerkship

• Students, residents, and attending faculty ask foreground clinical questions during rounds

• Students will create a PICO formatted question from a foreground clinical questions then search for relevant evidence from the literature.

• Students prepare and answer the PICO question based on search for evidence.

• Student prepares one EBM pearl (e.g., define and teach NNT)

•


Requirement during the IM clerkship on PICO

• Student will share the PICO with the resident team/ attending/ on teaching rounds

• Student will submit 2 PICO questions during IM clerkship in e‐value portal as part of requirement.


PICO


Clerkship Resources

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Internal Medicine Textbooks• IM Essentials for Students from ACP‐CDIM• MKSAP 6 for students • Case file in Internal Medicine• Kumar and Clark’s internal Medicine •• Reference textbooks: • Harrison’s Principles of Internal Medicine • Davidson’s Principle and Practice of Medicine• Goldman’s Cecil Medicine• Evidence Based Physical Diagnosis • Learning Clinical Reasoning (Kassirer)

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Physical Diagnosis Resources

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Databases & Journals

• PubMed•• OVID Medline•• Cochrane Library•• Dynamed•• UpToDate (On‐Campus)•• UpToDate (Off‐Campus & CME)• MICROMEDEX•• Natural Medicines (formerly Natural Standard)• Web of Science / Science Citation Index•• Henry Stewart Talks•• SciFinder•

• Annals of Internal Medicine• Blood• BMJ• Circulation• JACC• JAMA• Lancet• Nature Medicine• NEJM• PNAS

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Other POC Resources

• Drug Reference:• Epocrates• Tarascon Pharmacopoeia• Lexicomp• Micromedex• Sanford Guide (antibiotics)• Johns Hopkins Antibiotics Guide (antibiotics)

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The Keys to Excel in the Internal Medicine Clerkship

• Find out what your resident and preceptor expect from you. Try to meet their expectations.

• Be motivated and show your enthusiasm • Actively involved in your patient care• Go extra miles for your patients and your team• Follow through every assigned tasks related to patient care, reading , and

presentations • Read consistently about your patients, for NBME shelf examination and

ultimately CK and CS examination• Learn and practice to do succinct presentations about your patient on the

round• Ask good questions• Speak up and share your thoughts on the rounds and teaching

conferences• Actively seek feedback from everyone (residents, preceptors and nurses

etc.)


Internal Medicine Clerkship and AKI


Acute Kidney Injury


Case

• 72 year old male presents with left‐sided hemiparesis, On admission, was stuporous and tachypneic , Was recently treated for E. Coli urosepsis.

• PMH: – CKD– HTN– Arthritis

• Meds:– Lisinopril 20 mg daily– Naproxen 400 mg twice daily


Exam

• Vitals: Temp: 100.4 HR 88 RR 28 BP 130/66 SpO2 89% 2L O2, Flaccid left hemiparesis

• Obtunded• WBC 29.9 with 44% bands• UA: pyuria and bacteriuria

• CT head: no hemorrhage• CT chest: no PE•


Hospital Course

• Temp rises to 102, BP 78/50, intubated/mechanically ventilated• Given vancomycin, gentamicin, and cefepime• Cr 1.6 2.0, Urine output 20 ml/h• Urine output continues to fall, creatinine rises• Hemodialysis started on day 5• Hospital day 10 – fever 102.3 and hypotensive • Antibiotics broadened, IVF and vasopressors given• Dies on hospital day 12


Outline

• Common approach to kidney disease• Case• Definition/classification of AKI• Etiology, Impact on morbidity and mortality• Management• Basic clinical approach to Acid‐base disorder


Two key components of lab assessment

• m‐GFR and e‐GFR• The normal BUN‐Creatinine ration 10:1 or 15:1• GFR mat reduce by 50% before creatinine rise abvenormal limit !!

• The Crockcroft‐Gault equation to predict CrCl• MDRD is more accurate than above

• Radionuclide kidney clearance is gold standard


Urine Analysis

• Dipsticks ( Specific gravity, albumin, Glucose)• Hypo and Isosthenuria (loss of conc. and diluting capacity)

• Leucocyte esterase positive • Nitrate positive for bacteria• Only measure albumin ( 30‐300 mg/24 hrs)



Microscopic examination of the Urine

• Most useful is casts• Hematuria and cast – origin of blood• WBC cast• Eosinophil in urine• Dysmorphic RBC• Muddy Waxy Cast – Hallmark for ATN• Lipiduria, with heavy proteinuria – in cast seen as Maltese cross pattern




Measurement of Protein Excretion • Normal daily protein is less than 150 mg/24 hrs.• Total albumin lost in urine is less than 30 mg/24hrs• Gold standard is 24 hrs urine collection • A spot urine protein/creatinine ratio is easy way to estimate• Albumin/creatinine ratio between 30‐300 mg/24hs now called

as moderate increase albuminuria ( old – micro albuminuria)• Electrophoresis – help to identify types and relative quantities• Orthostatic proteinuria


Differentiate nephritic vs Nephrotic

Nephritic • Usually less than 3.5 gm/24

protein• Urine sediment : “Active”

Dysmorphic RBS, RBC cast,• Clinical : Hypertension , Oliguria,

Elevated serum creatinine• Pathology : Diffuse proliferative

GN, MPGN, IgA nephropathy, Crescentic GN

Nephrotic • Urinary Protein is usually more

than 3.5 gm/24 hrs.• Urine sediment: “bland” Hyaline

cast, Lipiduria, Oval fat bodies• Clinical : Low albumin,

Hyperlipidemia, Edema , Hypercoaguable

• Pathology: Minimal chain disease, FSGS, Membranous, Amyloid


Use of Radiological studies in Kidney Disease

Imaging study • Kidney USG

• Duplex USG and Angiography• Abdominal CT• CT angiography • MRI• Radionuclide Kidney Clearance

Scanning (GFR scanning)

Indication• Urinary tract obstruction, stone,

mass,. Cysts, location of kidney biopsy

• Renal artery stenosis• Obstruction, Stone, mass lesion• RAS, and renal vascular lesion• Cyst, Mass, RAS• GFR estimation, kidney Infarction


Acute renal failure - RIFLE


Acute Kidney Injury - AKI

• Abrupt and sustained reduction in kidney function marked by• Rise in serum creatinine• Reduced urine output (defined as <0.5 mL/kg/hrfor more than 6 hours)

• Rapid time course (less than 48 hours)


Systemic Impact of AKI

• May worsen acute lung injury– Increases pulmonary vascular permeability and neutrophil

infiltration via cytokine production

• Can lead to cardiac dysfunction– Stimulates inflammation, fibrosis, and apoptosis

• Can cause CNS damage– Increase in cerebral vascular permeability and inflammation

• Can predispose to development of CKD


Causes of AKI - Prerenal

• Altered hemodynamics• Hypovolemia• Decreased effective circulating volume

– CHF– Cirrhosis

• Renal autoregulatory failure– ACEI/ARB– NSAIDs


Causes of AKI - Postrenal

• Prostatic enlargement• Nephrolithiasis • Tumor • Fibrosis


Causes of AKI: Intrinsic Renal Failure

• Commonly caused by acute tubular necrosis (ATN) – Nephrotoxins:

• Contrast dye• Aminoglycosides • Mannitol

– Ischemia:• Shock • Sepsis • Major vascular surgery


Radiocontrast-induced Nephropathy

• Increase in Cr usually seen in 24‐48 hours• Prevention

– IVF– Use of low‐osmolality contrast– N‐acetylcysteine – no clear evidence– Hold diuretics and COX inhibitors and Metformin– IV fluids ( Normal Saline) prior to radiocontrast in DM helps



• Acute interstitial nephritis (AIN)– Beta‐lactams– Sulfonamides – Diuretics– Allopurinol– NSAIDs

• Associated with SLE, Sjogren’s, sarcoidosis



• Glomerulonephropathies:– Minimal change disease– Focal segmental glomerulosclerosis– Membranous nephropathy – with superimposed crescentic glomerulonephritis

– Renal vein thrombosis in nephrotic syndrome


Use of FENa in determining etiology of AKI

• Fractional excretion of sodium (FENa)• Can differentiate between prerenal and other causes

• FENa <1% prerenal• FENa >2% ATN• FENa 1‐2% either disorder


Treatment

• Diuretics do not shorten course of AKI or reduced need for dialysis

• Dopamine – no benefit• Stop nephrotoxic agents• Electrolyte management• Adequate nutrition


Conclusion

• AKI is a major cause of morbidity and mortality

• Treatment should be focused on optimizing hemodynamics and treating underlying cause

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Internal Medicine Clerkship: Learning from Patients - … · ROSS UNIVERSITY SCHOOL OF MEDICINE...

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