San Beda College of Medicine Program of Internal Medicine Clinical Clerkship in Internal Medicine Academic Year 2013-2014 1.

Program Description Internal Medicine is a 3-year program offered during the 2nd, 3rd and 4th years of medical education. Internal Medicine 1, offered during the 2nd year of medical education, involves the study of the basic concepts and principles in adult medicine. Internal Medicine 2, offered during the 3 rd year of medical education, involves the study of common diseases in the different subspecialties. Internal Medicine 3, offered during the 4th year of medical education, involves an 8-week clinical rotation. 2. Course Description Internal Medicine III is offered during clinical clerkship, designed to allow students the opportunity to participate in the non-surgical care of outpatient and hospitalized adult patients. It consists of an eightweek rotation in the Internal Medicine Department of the Quirino Memorial Medical Center. In the wards/ICU/OPD, clinical clerks are assigned to patients for history taking and physical examinations. The student participates in diagnostic and therapeutic care as a member of the medical team. They are responsible for daily notes and orders. Teaching and supervision are provided by the attending physician and residents on the service and other IM consultants. In addition to the availability of on-going department grand rounds and subspecialty conferences, a structured medical curriculum which includes formal student conferences and weekly case-based quizzes provides a didactic basis for this clerkship. 3. Aims / Goals/ General Objectives of the Internal Medicine Clinical Clerkship AIM: The aim of the program of Internal Medicine is for students to develop a comprehensive approach to the evaluation and care of the adult medical patient, congruent with the mission-vision of SBCM for its graduates to be the best primary health care provider. GOAL: After the eight-week clinical rotation in Internal Medicine, learners must be good primary internal medicine health care providers, who are active participants in the development and/or implementation of health care programs involving non-surgical adult patients, and must be partners in the promotion of health care for all adults. The OBJECTIVES of the Internal Medicine Clerkship Program are for students to: a. Elicit a problem-focused, complete and thorough medical history / information about a patient; adapt the thoroughness and focus of the history to the urgency of the medical situation and the time available. b. Perform a complete, comprehensive, and orderly physical examination in a technically correct and sensitive manner. c. Appropriately record in written format the information elicited. d. Perform basic and advanced skill procedures like: a. Basic venipuncture (including sterile techniques for blood cultures), IV line insertion, ABG sampling, urethral catheterization, NGT insertion b. Advanced (assist or observe) thoracentesis/chest tube insertion, lumbar puncture, bone marrow aspiration, paracentesis, endotracheal intubation e. Interpret appropriate laboratory/diagnostic procedures. f. Generate a differential diagnosis for each active problem in the problem list. g. Propose plan of management considering risks, benefits and costs of treatment options. h. Communicate systematically and concisely the data gathered from the history and physical examination including assessment and plan. i. Demonstrate professional attitude towards patients and the health care team.

4. The Clinical Learning Experience and its Evaluation

General Objective History taking skills and attitudes Physical Examination skills and attitudes Recording of information Performance of basic and some advanced skill procedures skills and attitudes Interpretation of appropriate laboratory/diagnostic procedures Generation of a differential diagnosis for each active problem in the problem list Proposal of a plan of management considering risks, benefits and costs of treatment options Reliable communication of information Demonstration of professional attitude towards patients and the health care team Teaching-Learning Strategy Eliciting a complete thorough patient history Performing the physical examination Patients charts Basic blood extraction, IV insertion, NGT insertion, catheterization, assisting in certain procedures Laboratory and ancillary facilities Evaluation Tool Oral Exam (Wards) Oral Exam (Wards) Written Case Procedures Form (c/o residents)

Bedside teaching rounds, management conferences Bedside teaching rounds, management conferences

Clinical Skils Exam Oral Exam Case Management Case-based quizzes Oral Exam Case Management Case-based quizzes Oral Exam Case Management OPD Lay Lecture Daily Admitting Conference Peer Evaluation Patient Evaluation

Communication with patients and the health team Interaction with patients and the health team

5. Grading System A. Written Exams Quizzes (Case-Based) Long Exam B. Oral Exam C. Clinical Skills (Lab Interpretation) Exam D. Case Presentation/Management E. OPD Lay Lecture TOTAL

30% 15% 20% 10% 20% 5% 100%

6. Rules and Regulations a. Admin Rule for Infractions - College rule with regards to absences, as stipulated in the student manual will apply during the clinical clerkship year (absences of more than 20%). Hence, unexcused absences of 11 DAYS OR MORE (20% of the rotation) will incur an AUTOMATIC GRADE OF 5.0. - Total number of hours of deficiencies is limited to a maximum of 160 hours, if a students total number of hours of deficiency exceeds 160 hours (to include penalties for lates and unexcused absences and demerits from late submission), he/she will be made to repeat the entire rotation. b. Attendance Official log-in time for all Pre-duty is 7 AM for morning post and 7 PM for evening post. The attendance logbook is located at the nurse station of the Medical ICU. The LOG-IN TIME SHOULD ALWAYS be COUNTERSIGNED by a resident or nurse at the ICU to be considered valid (ICU clock is the official time). There should be one (1) countersign for every clerk, (even if 2 or more clerks came in at the same time). Any erasures in the log-in time should also be countersigned. ABSENCE OF A COUNTER SIGNATURE WILL MAKE THE LOG-IN INVALID. Log-in after 10am will be considered ABSENT. Three (3) unexcused lates is equivalent to one (1) pre duty absence (8 hours).

Tampering with the logbook, like falsifying or altering your sign-in time or that of another clerks or signing in on behalf of another clerk (in which case, both parties will be reprimanded), is a very serious offense. The clerk/s involved will automatically get a grade of 5.0 (FAILED/repeat rotation). In the ward, clerks need to deck for their lunch break (2 groups). Lunch break is only one (1) hour, especially in the ICU and Ward. Clerks who are unaccounted for at any time during the day or their duty will be considered OUT OF POST and will automatically get one week extension. Make-up duties for absences is 1:3, unless a medical certificate is scanned/emailed to the Course Coordinator and submitted to the Student Prefect within 1 week of the absence for approval and (in which case, make up is only 1:1). Medical certificates must have the full name and contact number of the physician who made the certificate, for verification purposes. Medical certificates submitted more than 1 week after the last day of absence WILL NOT BE CONSIDERED VALID. A student who submits a false medical certificate will automatically get a grade of 5.0 (FAILED). For absences due to non-medical reasons, an excuse letter may be scanned and emailed to the Course Coordinator and submitted to the Student Prefect within 1 week from the last day of absence for approval. Make-up duties during the rotation are allowed only during weekends (Saturday - day or nighttime if there is no duty the day after) and Sunday daytime, up to 8 pm). Straight 24-hour duties are not allowed (maximum 16 hrs only). Make-up duties, even if done during Sundays/holidays or Holy Week, are equivalent to 1:1 only. Index cards of make-up duties completed during the IM rotation must be scanned/emailed to the Course Coordinator right after the rotation. Make-ups done after the IM rotation (but before the end of clerkship) will only be allowed with a written consent of the senior resident of his present rotation (to avoid duplication and straight 24-hr duties). Make-up duties done after the end of clerkship should be documented using the official SBC make-up form.

c. Tour of Duty and Responsibilities Areas of Rotation During the eight-week rotation, clerks will rotate in the following areas: OPD, Wards and ICU. Patient Care Logbook Each clerk should keep a patient care logbook. This is where they write the cases they have handled in the wards/ICU and OPD and procedures they have observed or performed. Required skills include: venipuncture, IV line insertion, NGT and foley cath insertion, ABG sampling and taking a 12L ECG. Special procedures include: thoracentesis, chest tube insertion, paracentesis, lumbar puncture and endotracheal intubation. Ward/ICU Rotation Each clerk will be assigned a number of patients. They should introduce themselves properly to their patients and should follow-up them up daily until they are discharged or until he/she transfers to another post. For these patients, they are also required to write Admitting notes (within 48 hours of admission) which they will attach to the patients chart. When a consultant makes bedside teaching rounds, they should be ready to present their cases anytime. Clerks must wear their IDs/pins at all times. Students must also submit one (1) written Case Discussion/Report (via email to the Course Coordinator) at the end of the rotation, using a standard format. This must also be printed out and submitted to the Chairman of the QMMC Department of Medicine. Failure to submit on time will incur a demerit of 2 hours per day late. OPD Rotation In the OPD, clerks should log their patients in their logbook to include the complete patients name and initial diagnosis. The OPD resident should sign their logbook after each OPD day. Once a week, each clerk may rotate with one (1) subspecialty clinic of choice, including Derma. They should obtain the history/PE (new cases only) and present the case to the 2nd year resident. Only 1 clerk can rotate with a subspecialty at any time. Subspecialty clinics include: DM, Cardio, Pulmo, Gastro, Rheuma and Derma. The notebook will be submitted for checking during the lay lecture. As part of their training in educating patients, clerks are required to hold lay lectures in the OPD hallway. Topics will be assigned at the start of the rotation. 2 clerks will discuss one topic and will be

graded by the Course Coordinator. Each clerk should have a speaking part during the lay lecture. Topics include: PTB, DM, Viral Hepatitis, Dengue, PUD, hypertension, HIV. Written Exams Case-based quizzes are given weekly covering the topics assigned for that week. One long exam will also be given at the end of IM rotation (computerized). Students with unexcused absences in the quizzes/long exam will automatically get a grade of zero. Oral Exam The oral exam will be held at the medical wards. The clerk will be assigned a patient to interview and examine. He/She will then present the case to a consultant and will be evaluated based on knowledge of diagnosis and management of the case. The orals will start on the fifth week of rotation and held once a week (4-5 clerks at a time). Clinical Skills Exam A clinical skills exam will be given at SBC right after the long exam. Coverage includes identifying/interpreting abnormal PE findings, interpretation of ECG, chest Xray, ABGs, common laboratory procedures, lab abnormalities (i.e. differentials for electrolyte abnormalities), and rational antibiotic/IV fluid use. Case Management Conference Each clerk must present one case seen in the ward or ICU during the weekly case management conference (powerpoint presentation), during which 1-3 consultants will evaluate his knowledge of the case (history, PE, differentials and management). Clerks must email the case to the Course Coordinator a day prior to the case management conference. Attendance is compulsory. Failure to attend any conference (unexcused) will incur 9 hours demerit. The topics for presentation include:
1st week - Pulmo - pleural effusion, PTB/pneumonia, Asthma/COPD 2nd week - Gastro UGIB/PUD, LGIB, Hepatitis or Cirrhosis, Pancreatitis, Biliary Disease (maximum 4 cases) 3rd week - Cardio - ACS, CHF, HPN/Hypertensive urgency 4th week Infectious malaria, typhoid fever, dengue/chinkungunya, leptospirosis, STD/HIV 5th week Nephro - AKI, CKD, acute pyelonephritis 6th week Endo DM, DKA/thyroid

Conferences/Lectures Admitting conferences are conducted every morning (weekdays) wherein clerks are required to present the admissions the day before. The QMMC Department of Medicine also holds regular Grand Rounds and subspecialty conferences during the week. Tentative schedule of conferences are as follows:
Mon Infectious Ds Infectious Ds Infectious Ds Allergo Infectious Ds Tue Hematology Pulmonology Hematology Pulmonology Wed Endo Nephro Nephro, Endo Neurology Thurs Medical Grand Rounds (MGR) MGR, Rheuma MGR MGR Fri Cardiology Gastro Cardiology Sat Gastro

These conferences and lectures are the priority of each clerk over ward, ICU or OPD work. (Take note that there are no department conferences during the whole month of December). Peer/IM Rotation Clerks are required to evaluate their peers and the IM clerkship and to submit their evaluation at the end of the rotation (via email). Deadline is the last Friday of the rotation.

MUST KNOW TOPICS in Internal Medicine III

Endocrinology - DM and complications - DKA - Thyroid diseases Infectious diseases -Typhoid/ Dengue fever, Malaria - UTI, Leptospirosis, Rabies - Rheumatic fever -Sepsis and septic shock - Anti-infective therapy Nephrology - Acute renal failure - Chronic renal failure - Electrolyte imbalance - Acid-base disorders - UTI Hematology - Approach to anemia Rheumatology - Approach to joint pain - SLE - Rheumatoid arthritis - Osteoarthritis - Crystal induced arthropathies Allergy /Dermatology - Approach to rashes - Adverse drug reaction - Common dermatologic diseases

Cardiovascular - Approach to chest pain - Approach to hypertension - Acute coronary syndromes - Ischemic heart disease - Atrial fibrillation - Dyslipidemia - Congestive heart failure

Gastroenterology - Approach to GI bleeding - Approach to jaundice - Approach to abdominal pain - Diarrhea and constipation - Peptic ulcer disease - Hepatitis/Cirrhosis - Pancreatitis - Gallbladder/Biliary diseases Pulmonary - Approach to cough / hemoptysis - Approach to dyspnea/wheezing - Pneumonia - Bronchial asthma/COPD - Pleural effusion - Tuberculosis - Pulmonary embolism/DVT - Respiratory failure - Pulmonary masses

Department of Internal Medicine Chair: Norman Maghuyop, MD Course Coordinator: Ma. Fredelita C. Asuncion, MD Email: dr_del_asuncion@yahoo.com Contact Number: 0917-8140926 (globe) /0922-3510029 (sun) / 02-7107410/02-5792133(mobile landline) QMMC Instructors: A. Name: Ma. Fredelita Asuncion Credentials: Diplomate in Internal Medicine/Allergy, Immunology B. Name: Norman Maghuyop Credentials: Diplomate in Internal Medicine/Pulmonary Medicine C. Name: Carmen Chungunco Credentials: Diplomate in Internal Medicine/Cardiology D. Name: Anne Margaret Ang Credentials: Diplomate in Internal Medicine/Nephrology E. Name: Marissa Lim Credentials: Diplomate in Internal Medicine/Nephrology F. Name: Romeo Merino Credentials: Diplomate in Internal Medicine/Cardiology G. Name: Rosaly Zamora Credentials: Diplomate in Internal Medicine/Infectious Disease H. Name: Queenie Ngalob Credentials: Diplomate in Internal Medicine/Endocrinology

REFERENCES 1) Harrison's Principles of Internal Medicine, 18th Edition by A. Fauci, Eugene Braunwald, et al. 2) Symptom to Diagnosis: An Evidence Based Guide, 2nd Edition by Scott Stern, Diane Altkorn 3) Current Medical Diagnosis and Treatment 2013 by Maxine Papadakis, Stephen McPhee 4) Bates' Guide to Physical Examination and History Taking, 10th Edition, Lynn S. Bickley