Goals and Objectives

Goals

1. Following this elective, the resident will have increased comfort in evaluating and managing common pulmonary complaints and diseases encountered in the outpatient family medicine practice.

2. The resident will have increased experience and comfort in the common pulmonary procedures, including thoracentesis, PFT interpretation, bronchoscopy, and imaging interpretation.

Objectives

1. Pneumonia

   • Knowledge

     1. Define and differentiate CAP, HCAP, and HAP.

     2. List risk factors for Drug Resistant Strep pneumonia(DRSP) and antibiotic treatment for DRSP.

     3. Recognize the risk factors for multi-drug resistant organisms (MDR) and appropriate empiric antibiotic coverage for MDR organisms.

     4. Describe the indicated tests required to evaluate and treat pneumonia.

     5. Predict risk for morbidity and mortality from CAP using an EBM tools such as PORT score or CURB-65 score.

   • Patient Care

     1. Elicit a focused history to identify symptoms consistent with pneumonia.

     2. Perform a targeted physical examination to elicit signs consistent with pneumonia and differentiate it from other mimicking conditions.

     3. Select and interpret indicated laboratory, microbiologic, and radiological studies, including interpretation of cxr and CT scans of the chest, to confirm the diagnosis of pneumonia and risk stratify patients.

     4. Apply EBM tools to triage decisions and identify factors that support the need for inpatient treatment or ICU admission.

     5. Initiate empiric antibiotic selection based on risk factors that follow the national guidelines.

     6. Recognize and address complications of pneumonia and/or inadequate response to therapy.

   • Interpersonal Communications

     1. Communicate with patients and families to explain the history and prognosis of pneumonia.

     2. Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and required follow up.

     3. Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

   • Professionalism

     1. Recognize the indications for specialty consultation.

2. Asthma

   • Knowledge

     1. Define asthma and escribe the phathophysiologic process that lead to reversible airway obstruction and inflammation.

     2. Identify precipitants of asthma exacerbations.

     3. Recognize and differentiate the clinical presenation of asthma from other acute respiratory and non-respiratory syndromes.

     4. Describe the role of diagnostic testing, including peak flow monitoring, used for the evaluation of asthma exacerbation.

     5. Describe EBM therapies for the treatment of asthma exacerbations, which may include bronchodilators, systemic corticosteroids, and and oxygen.

     6. Explain indications, contraindications, and mechanism of action of pharmacologic agens used to treat asthma.

     7. Explain the indications for invasive ventilatory support.

     8. List the risk factors for disease severity and death from asthma.

     9. Describe the typical acid/base findings for patients with an acute asthma exacerbation

   • Patient Care

     1. Elicit a focused history to identify triggers of asthma and symptoms consistent with asthma exacerbation.

     2. Perform a targeted physical examination to elicit signs consistent with asthma exacerbations, differentiate findings from other mimicking conditions, and assess severity of illness.

     3. Select and inerpret appropriate diagnostic studies to evaluate severity of asthma exacerbation.

     4. Prescribe appropriate EBM pharmacolgic therapies to treat asthma.

   • Interpersonal Communication Skills

     1. Communicate with patients and families to explain the natural history and prognosis of asthma.

     2. Communicate with patients and family to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation and modification of environmental exposures, and required follow-up care.

     3. Communicate with patients and families to explain discharge medications, potential side effects, duration of therapy and dosing, and taper schedule.

     4. Differentiate for patients and families the indications and appropriate use of daily use inhalers and rescue inhalers for asthmatic control.

     5. Communicate with patients and families to explain symptoms and signs that should prompt emergent medical management.

   • Professionalism

     1. Recognize indications for specialty consultation.

3. Pulmonary Nodule

   • Knowledge

     1. List the differential for the incidental pulmonary nodule, including infectious and malignant etiologies.

     2. Recognize worrisome historical and x-ray findings, raising suspicion for possible malignancy.

     3. Describe the diagnostic approach to an incidental pulmonary nodule.

   • Patient Care

     1. Perform a focused history identifying risks factors for infectious vs malignancy.

     2. Perform a focused, pertinent physical exam, evaluating for physical exam findings for malignant, including metastatic, etiologies for an incidental pulmonary nodule.

     3. Order appropriate, cost-effective studies to further evaluate an incidental pulmonary nodule.

     4. Interpret imaging and laboratory studies evaluating pulmonary nodules, recognizing worrisome findings consistent with malignancy.

   • Interpersonal Communication Skills

     1. Communicate with families and patients the possible diagnosis of a pulmonary nodule and the work-up.

     2. Explain the risks vs benefits of the work-up for a pulmonary nodule.

   • Professionalism

     1. Identify patients requiring referral to pulmonary.

4. COPD

   • Knowledge

     1. Define COPD and describe the basic pathophysiologic processes.

     2. Describe potential precipitants of exacerbation, including infectious and non-infectious etiologies.

     3. Recognize and differentiate the clinical presentation of COPD exacerbation from other acute respiratory and nonrespiratory syndromes.

     4. Describe the role of diagnostic testing used for evaluation of COPD exacerbations.

     5. Describe the evidence based therapies of treatment of COPD, differentiating treatments that provide mortality vs morbidity benefit.

     6. List the indicators of disease severity.

     7. Recognize the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.

     8. Describe the typical acid/base findings for patients with COPD (acute and chronic).

   • Patient Care

     1. Elicit a focused history to identify symptoms consistent with COPD exacerbation and etiologic precipitants.

     2. Perform a targeted physical examination to elicit signs consistent with COPD exacerbation, differentiate it from other mimicking conditions, and assess severity of illness.

     3. Diagnose patients with COPD using history, physical examination, radiographic data, and pulmonary function test.

     4. Select and interpret appropriate diagnostic studies to evaluate severity of COPD, including PFT interpretation.

     5. Recognize symptoms, signs, and severity of impending respiratory failure.

     6. Prescribe appropriate evidence based pharmacologic therapies during COPD, using the most appropriate route, dose, frequency, and duration of treatment.

   • Interpersonal Communication Skills

     1. Communicate with patients and families to explain the natural history and prognosis of COPD.

     2. Communicate with patients and families to explain the goals of care plan, including clinical stability criteria, the importance of prevention measures such as smoking cessation, and required follow-up care.

     3. Communicate with patients and families to explain medications, potential side effects, duration of therapy, and dosing, and taper schedule.

     4. Dialogue with patients and families regarding care goals and limitations, including palliative care and end-of-life wishes.

   • Professionalism

     1. Recognize indications for specialty consultation.

5. Pleural Effusion

   • Knowledge

     1. List the causes of pleural effusions, differentiating between loculated vs free flowing and exudative vs transudative.

     2. List the Light’s Criteria for identifying exudative vs transudative effusions.

     3. List the causes for neutrophilic predominate vs lymphocytic predominate exudative effusions.

     4. List the indications for thoracentesis.

     5. List the complications of thoracentesis.

   • Patient Care

     1. Perform an exam identifying a pleural effusion and size of the pleural effusion.

     2. Order the correct imaging studies to identify a pleural effusion and categorize as loculated vs free flowing.

     3. Identify patients who require emergent thoracentesis.

     4. Order appropriate studies to evaluate pleural fluid.

     5. Perform thoracentesis.

   • Interpersonal Communication Skills

     1. Communicate with patients the natural history and common etiology for pleural effusions.

     2. Explain the risks vs benefits for a thoracentesis to patients in family.

   • Professionalism

     1. Identify patients requiring urgent consultation from pulmonary.

6. Undifferentiated Dyspneic Patient

   • Knowledge

     1. Describe the diagnostic approach to the undifferentiated dyspneic patient.

     2. List the indications for HRCT, PFT, and bronchoscopy.

     3. Recognize the important environmental and infectious exposures that can lead to pulmonary disease.

     4. Differentiate restrictive lung diseases vs obstructive lung diseases.

     5. List the common causes for obstructive lung diseases.

     6. Be familiar with the different ILD and their presentation.

   • Patient Care

     1. Elicit a focused history, paying special attention to environmental, infectious, and iatrogenic exposures.

     2. Order appropriate, cost-effective studies for the dyspneic patient.

     3. Basic interpretation of PFTs, recognizing restrictive vs obstructive patterns.

     4. Perform a targeted physical exam on the dyspneic patient.

     5. Recognize patients requiring urgent referral and evaluation.

     6. Interpret cxr and HRCT, recognizing common patterns.

   • Interpersonal Communication Skills

     1. Communicate with families and patients the work-up and differential for dyspneic patients.

   • Professionalism

     1. Identify patients requiring referral and evaluation by pulmonary.