College of Medicine

1. Inpatient Internal Medicine-Pediatrics PACE Subcommittee Maria Cannarozzi, M.D. December 16, 2004 College of Medicine

2. “Disease in the context of a lifetime” Incorporate ILC topics via innovative learning experiences Emphasize pathophysiology common to both pediatrics and adult medicine Unify two clerkships Preserve mutual exclusivity Objectives USF College of Medicine Internal Medicine-Pediatrics PACE Subcommittee Maria Cannarozzi, M.D. Sir William Osler http://www.medicalarchives.jhmi.edu/sgml/osler.html

3. Nonintegrated vs Integrated Weekly themes Conferences Integrated longitudinal curriculum Components

4. Nonintegrated Patient encounters and ward experience Case based conference Integrated Keynote conference ILC Clinical modules ECG lecture series Clerkship Curriculum

5. 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 Weekly Themes

6. Keynote Case Based Conference ECG Conferences

7. -- 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 Integrated Longitudinal CurriculumWeekly Task

8. Sample Week 2: Pulmonary

9. 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 Student Portfolio A closer look…

10. Inpatient Internal Medicine-Pediatrics On Line Curriculum Keynote Conference Weekly Task Clinical Modules

11. 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 Assessment

12. 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 Further Considerations

14. ILC Weekly Task Sir William Osler http://www.medicalarchives.jhmi.edu/osler/oslerroom.htm

15. “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 stored How the order and medication/blood product are verified to match How the medication/blood product is transported to the ward The name and role of everyone on the ward who processes or delivers the medication/blood product to the person who administers it The supplies needed to administer the medication/blood product to the patient The verification process for ensuring the medication/blood product given to the patient is correct The manner in which the medication/blood product is administered including equipment, rates, and site of entry Any counseling or information the patient/patient’s relative received by anyone involved in the entire process regarding the medication/blood product The time for the entire process to occur What 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

16. 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? Sir William Osler http://www.medicalarchives.jhmi.edu/osler/oslerroom.htm

17. USF HEALTH SCIENCES CENTER Keynote Conference Agenda for Week 2: Pulmonary medicine Representative Faculty:  Pulmonologist, general internist, general pediatrician, basic sciences physiologist, pharmacologist

18. 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. Keynote Conference Agenda for Week 2: Pulmonary medicine

19. Pulmonary Function Test • Spirometry • Slow maneuvers • Forced maximal maneuvers • Lung Volumes • Plethysmography • Inert gas washout/dilution • Planimetry • Diffusion Capacity • Pulmonary Mechanics • NIP, MVV, MEP

20. A 72-year-old woman with long standing tobacco use (150 pack years) undergoes PFT testing for evaluation of increasing dyspnea. Case # 3

21. Spirometry Results Flow volume loop Effort loop Severely blunted exp curve Both are smooth in contour

22. Pronounced air trapping with lung fields below breast shadows

23. What is the most likely diagnosis? Asthma Asbestosis Neuromuscular weakness COPD Question