Introduction to Clinical Medicine I

Total Contact Hours:

90 hours

Course Director:

S. Bruce Binder, M.D., Ph.D., Associate Professor of Family Medicine and Pharmacology

Course Description:

This year-long course meets one day each week and has a combination of lecture, small group, office preceptor, and standardized patient learning activities. Students learn the fundamentals of building a relationship with a patient, how to gather relevant information, and conduct a physical examination. In small group settings, students and faculty discuss the special challenges of caring for patients from diverse backgrounds, how to recognize one's own biases, and how to work effectively and ethically in difficult situations. At several points during the year, each student must demonstrate what he/she has learned by conducting a comprehensive interview and sections of the physical examination on standardized patients. In addition, each student will work with a primary care physician (pediatrics, family medicine, internal medicine) for a half-day each week for a portion of the year, learning about the complexities of providing comprehensive health care.

Course Objectives & Integration with the Educational Objectives:

By the conclusion of this course, the student will demonstrate the ability to:

K1 Build an accurate and thorough patient history during a patient interview, including the following components:

• Chief complaint
• History of present illness (including seven attributes of a symptom)
• Past and current medical history
• Family history
• Social and cultural history
• Review of systems

K2 Identify the following anatomical landmarks in pictures and on patients:

• Normal tympanic membrane: Malleus, Pars flaccida, Pars tensa, Incus
• Nasal cavity: Middle turbinate, Inferior turbinate, Middle meatus, Nasal septum
• Lymph nodes of the head and neck: 10 sets as delineated by Bates text
• Thyroid and cricoid cartilages and trachea
• Eye: pupil, iris, sclera, conjunctiva, medial and lateral canthi, lacrimal puncta
• Eye: optic disk; physiologic cup; macula; fovea; demonstrate an ability to differentiate arterioles and veins based on color, size, and light reflection
• shoulder: sternoclavicular joint, acromioclavicular joint, subacromial area, bicipital groove
• Knee: tibial tuberosity, patellar tendon
• Thorax/Lung: five lobes of lung anteriorly, posteriorly, and laterally; accessory muscles of respiration
• Heart: aortic, pulmonic, tricuspid, and mitral "areas of auscultation"

K3 Perform the following general physical examination skills:

1. Head, ear, nose, sinus, mouth, throat, and neck
Demonstrate proper technique(s) for:

• Otoscopic examination of the ear
• Testing gross hearing by use of the whispered voice or finger rub
• The Weber test
• The Rinne test
• The nasal examination using an otoscope with nasal speculum
• Sinus palpation with identification of the sinuses being palpated
• Sinus transillumination
• Examination of lips, buccal mucosa, gums, teeth, and roof of mouth
• Examination of the tongue, including examination of CN 12 and palpation where appropriate
• Examination of the pharynx, including proper use of the tongue blade and testing of CN 10
• Examination of the ten sets of head and neck lymph nodes as delineated by Bates text
• Palpation of the thyroid gland

2. Eye
Demonstrate an understanding of:

• The measurement of visual acuity, including office methods to measure it. Explain standard method of describing acuity (e.g., 20/40).
• The working parts of the ophthalmoscope, including the rheostat, lens disc, aperture disc
• The functional anatomy of the nearsighted and farsighted eye, and what alterations are required in the lens disc of the ophthalmoscope to view these eyes appropriately

Demonstrate appropriate technique(s) for:

• Assessing visual fields
• Examination of the eyelid, including attention to width of palpebral fissures, edema of the lids, color of the lids, presence or absence of lesions, condition and direction of eyelashes, and adequacy with which the eyelids close
• Examination of the conjunctivae and sclera
• Eversion of the upper eyelid
• Assessment of anisocoria
• Assessment of pupillary responses (direct, consensual, accommodative). Know which is which.
• Assessment of extraocular movements
• Handling an ophthalmoscope to view patients' left and right eye (appropriate hand, eye use, hand position, etc.)
• Viewing the retina of each eye

Demonstrate the ability to:

• Elicit and view the red reflex in each eye
• Find the right and left optic discs

3. Musculoskeletal exam of the spine and upper and lower extremities
Demonstrate appropriate technique(s) for:

• Examination of the temporomandibular joint
• Palpation of the cervical spine
• Assessment of range of motion of the cervical spine (flexion, extension, rotation, lateral bending)
• Assessment of range of motion in the hand and wrist (flexion, extension, radial and ulnar deviation)
• Palpation of the DIPs, PIPs, MCPs, and wrist joint
• Inspection and palpation of the elbow
• Assessment of range of motion of the elbow (flexion, extension, pronation, supination)
• Inspection and palpation of the shoulder
• Assessment of range of motion of the shoulder. Isolate each movement (flexion, extension, abduction, adduction, internal rotation, external rotation).
• Assessment of muscle strength in the upper extremity (all movements at the shoulder, elbow, wrist, and hand and fingers
• Assessment of Phalen and Tinel signs
• Inspection of the feet
• Palpation of the ankle, MTPs, and IP joints
• Assessment of range of motion of the ankle, including tibiotalar joint (dorsiflexion and plantarflexion), subtalar joint (inversion and eversion of foot), transverse talar joint (inversion and eversion of forefoot), MTPs, IPs
• Inspection and palpation of the knee
• Assessment of range of motion of the knee (flexion and extension)
• Assessment of range of motion of the hips (internal and external rotation, abduction and adduction, flexion and extension)
• Inspection of the spine for curvature (anteroposterior and lateral)
• Assessment of range of motion of the back (flexion, extension, rotation, lateral bending)
• Performing a straight leg raise
• Assessment of muscle strength throughout the lower extremity (all movements at the hip, knee, and ankle)

4. Cardiovascular system
Demonstrate appropriate technique(s) for:

• Inspection of the general cardiovascular system, noting the general appearance of the patient as it relates to the CV system, the respiratory pattern as it relates to the CV system, observable pulsations, jugular venous distention, jugular venous pulsations, apical pulse or movements of the left ventricle visualized on the anterior chest wall
• Assessment of systolic and diastolic blood pressure
• Palpation of the apical pulse
• Cardiac percussion, noting the change from cardiac dullness in the 3rd, 4th, 5th, and 6th interspaces to demarcate lower borders of the heart
• Auscultation of the heart, including identifying on the patient the "aortic," "pulmonic," "tricuspid," and "mitral" areas, and using both the diaphragm and bell of the stethoscope
• Auscultation of the heart with the patient in the left lateral position, and with the patient leaning forward in complete exhalation (for aortic murmurs)

Demonstrate the ability to:

• Identify S1 and S2, including knowledge of splitting of S2 and auscultating for it in the proper anatomic position
• Recognize the presence of an abnormal heart sound

5. Abdomen
Demonstrate the ability to:

• Properly position the patient for optimal abdominal examination
• Position a patient using the appropriate anatomic positions to auscultate for bruits of the aorta and renal, iliac, and femoral arteries

Demonstrate appropriate technique(s) for:

• Inspection of the abdomen, including commentary on the presence or absence of scars, striae, and dilated veins; the contour of the abdomen (flat, rounded, protuberant or scaphoid); symmetry; peristalsis; and pulsations
• Auscultation of the abdomen in all four quadrants, including description of bowel sounds in terms of frequency and character
• Percussion of the abdomen. Using this technique, measure the liver span in the mid-clavicular line.
• Both gentle and deep palpation of the abdomen. Comment on any areas of tenderness or increased resistance to palpation.
• Eliciting signs of peritoneal irritation by means of the cough reflex and rebound tenderness
• Palpating hepatomegaly or splenomegaly
• Palpation of the abdominal aortic pulsations
• Testing for shifting dullness
• Testing for the presence of a fluid wave

6. Peripheral vascular system
Demonstrate appropriate technique(s) for:

• Inspection of the arms and forearms, with attention to size, symmetry and swelling; venous pattern; color and texture of skin; and nail beds
• Inspection of the lower extremities, with attention to size, symmetry and swelling; venous enlargement; unusual pigmentation, rashes, scars, or ulcerations; texture and color of skin; nail beds; distribution of hair on the lower legs, feet, and toes
• Palpation of the carotid, brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial pulses
• Detecting edema
• Detecting varicosities. Describe their appearance.
• Performing an Allen test
• Assessment of systolic and diastolic blood pressure
• Assessment of capillary refill

7. Lung/thorax
Demonstrate appropriate technique(s) for:

• Evaluation of symmetrical chest expansion by palpation (Bates page 233)
• Assessment of tactile fremitus. Describe what is "normal."
• Percussion of lung fields. Differentiate between dull and resonant percussion sounds. Utilize this differentiation to locate the diaphragm on a patient and measure its movement with respiration.
• Auscultation of the lungs. Describe the nature of the breath sounds heard.
• Assessing egophony. Describe what is "normal."
• Assessing whispered voice sounds. Describe what is "normal."

8. Neurological exam
Demonstrate appropriate technique(s) for:

• Eliciting the biceps, triceps, brachioradialis, patellar, ankle, and jaw jerk reflexes (in both the supine and seated positions). Know the nerve roots associated with each.
• Use of reinforcement to help elicit deep tendon reflexes
• Eliciting superficial abdominal reflexes
• Eliciting a plantar reflex
• Eliciting ankle clonus
• Assessing a glabellar reflex
• Assessing the following meningeal and nerve root signs, and describe to your preceptor what an abnormal response would be:
• Nuchal rigidity
• Kernig sign
• Brudzinski sign
• Straight leg raising
• Assessing the patient's normal (usual) gait and their ability to turn quickly, arise from a chair, walk on their heels, walk on their toes, perform a deep knee bend or hop on one leg, and tandem walk
• Assessing (cerebellar signs) rapid alternating movement, finger-nose test, heel-knee-shin test, rapid finger tapping
• Inspection of muscles and muscle tone
• Assessing pronator drift
• Assessment of motor strength as noted in the musculoskeletal competency sets
• Assessing Cranial Nerve II via assessment of visual acuity, assessment of visual fields by confrontation, and fundoscopy
• Assessing function of Cranial Nerves III, IV, and VI by observation of the eyelids for ptosis, retraction, lid lag, or abnormalities in blink; observation of the pupils for size, shape, equality, and regularity of margins; direct, consensual, and accommodative pupillary responses; swinging light test from one pupil to other every five seconds (both should remain constricted); observation of gaze fixation for movements, dysconjugate gaze, symmetry of corneal light reflex; cover/uncover test; conjugate gaze in all directions; ocular muscles in each eye separately; and convergence of gaze
• Assessing function of Cranial Nerve V by assessment of pain and light touch sensation in the distribution of al three divisions of CN V bilaterally; assessment of motor function; and assessment of the jaw jerk reflex
• Assessing function of Cranial Nerve VII by observation of facial muscles for symmetry during conversation; having the patient wrinkle their forehead, look up, close their eyes tightly; having the patient smile, show their teeth, purse their lips, whistle, puff their cheeks out
• Assessment of Cranial Nerve VIII by testing hearing by whispered voice or finger rub, Weber test, Rinne test
• Assessment of Cranial Nerves IX and X by observation of the palate and uvula at rest and during movement for symmetry; by testing the gag reflex on each side. (Know this is part of the assessment of these Cranial Nerves. We will not have to gag one another in small groups nor on the OSCE.)
• Assessment of Cranial Nerve XI by assessment of motor function of the sternomastoid and trapezius
• Assessment of Cranial Nerve XII by having the patient stick out their tongue and move repeatedly side-to-side or in and out
• Assessment of positional sense of the lower extremity (proprioception)
• Assessment of vibrational sense in the medial malleolus, great toe, and MCP
• Assessment of stereognosis
• Assessment of graphesthesia
• Assessment of light touch sensation
• Assessment of double simultaneous stimulation (sensory integration)

Demonstrate the ability to:

• Perform a Romburg test
• Perform tests for postural reflexes
• Demonstrate an understanding of:
• What specific tests to do for each cranial nerve (e.g., "Assess function of Cranial Nerve XI" or "Assess the function of the Motor component of Cranial Nerve V" would be legitimate questions on the OSCE.)

K4 Identify important differences in the approach to and examination of the neonate, toddler, and adolescent

C1 Establish and build a professional relationship with a patient, with special attention to the following:

• Professional appearance (appropriate attire, not chewing gum, etc.)
• Calling the patient by their appropriate name
• Shaking the patient's hand in introduction
• Introducing oneself (first and last names, as a medical student working with Dr. ______)
• Establishing and maintaining rapport with the patient
• Establishing and maintaining appropriate eye contact during the interview
• Exhibiting a non-judgmental attitude, awareness and sensitivity to issues of culture, ethnicity, gender, and sexual orientation
• Making the patient feel comfortable (not awkward, threatened, etc.)

C2 Communicate effectively with patients while building an accurate and thorough patient history, with special attention to the following:

• Begin with "What brings you in," "What can I do for you," or a variant.
• When the patient responds with a symptom or brief answer (e.g., "My throat hurts."), respond with "Tell me about it," "Tell me more," or something similar.
• Allow the patient adequate time to answer before moving on to the next question.
• Use a good mix of open-ended and directed questions.
• Exhibit active listening skills (appropriate head nodding, body language, etc.).
• Use reflection, clarification, summarization when appropriate.
• General flow of interview is smooth with good transitions; generally good organization
• Express appropriate empathy in situations where it is called for.
• Avoid the following:
• Use of medical jargon or terminology
• Leading the patient, either verbally or non-verbally
• Nervous habits (fidgeting, playing with hair, clicking pen, etc.)
• Asking multiple questions simultaneously
• Overdependence on a preformed set of questions (mental)

C3 Communicate effectively with preceptors and their office staff regarding scheduling, with prompt communication regarding any unforeseen cancellations

C4 Receive oral and written feedback from faculty, patients, and simulated patients in a respectful manner, and use that feedback to improve skills in succeeding encounters

C5 Reflect in written form on interviews with volunteer patients (three), including self-assessment of performance, strengths, weaknesses, and specific areas needing improvement

P1 Exhibit professionalism through:

• Attending classes and required workshops
• Being punctual to all classes
• Displaying a positive attitude (especially in the presence of patients)
• Dressing in a professional manner when required
• Being truthful
• Being reliable (showing up when supposed to, calling ahead when unable to)
• Showing commitment to relationship with preceptor
• Being prepared for meetings with preceptors
• Being courteous to patients (real and simulated), patients' families, staff, colleagues, faculty, and other health professionals
• Maintaining confidentiality regarding patient care
• Demonstrating respect, empathy, responsiveness, and concern regardless of a patient's problems, personal characteristics, or cultural background
• Contributing to a positive learning environment, collaborating with colleagues, and performing self-assessment and self-directed learning

Syllabi:

• Course Materials

Learning Activities:

Presentations, small group discussions and physical exam skills training, preceptorships in community practice offices.

Assessment:

Small group participation, preceptor evaluations, Objective Structured Clinical Exams (OSCEs), supervised interviews, MCQ exams, reflective statements.