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					                   ตารางการปฏิบัติงานพจบ./พชท.หน่วย AIR

On service staff         ศ.พญ รัตนวดี ณ นคร
                         รศ. นพ. ศิรภพ สุวรรณโรจน์
                         ผศ. พญ. อรรจนี มหรรฆานุเคราะห์
                         อ. พญ. ชิงชิง ฟูเจริญ

จันทร์ 07.00-09.00 น.           Self ward round
       09.00-13.00 น.           Out-patient care in rheumatology (OPD 8)
                                (clinical attachment1 อ. รัตนวดี, อ. อรรจนี)
        14.00-16.00      น.     Ward round2

อังคาร 08.00-10.30 น.           Ward round2
       10.30-12.00 น.           Consultation round AE3/2จ3
       13.00-17.00 น.           Clerkship in AIR clinic (OPD 8) 4

พุธ     07.00-08.30 น.          Self ward round
        09.00-13.00 น.          Out-patient care in rheumatology1 (OPD 8)
                                (clinical attachment1 อ. ศิรภพ)
        14.00-17.00 น.          Ward round2 and Self study (see program)5

พฤหัสบดี08.00-10.30 น.          Ward round2
      10.30-12.00 น.            Consultation round 4ก/4ค 3
      13.00-17.00 น.            Self study (see program)5

ศุกร์   08.00-09.30 น.          Topic discussion6
        09.30-10.30 น.          Ward round2 (problem case round)
        10.30-12.30 น.          Scleroderma clinic7
        14.00-17.00 น.          Self study (see program)5




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                                      Training Objective

1. Objective of Clinical attachment with on service staff at OPD
         “State of Art in Rheumatic Patients Care : Holistic Approach, Clinical Reasoning, and
Informative Medicine”
1.1 To gain an experience in taking care of common rheumatic problems.
      Nonarticular rheumatism : stenosing digital tendinitis, De Quervain syndrome,
         lateral/medial epichondylitis, supraspinatous tendinitis, pes ancerinitis, Archiles
         enthesitis, retrocalcaneal bursitis, plantar fasciitis, plica syndrome, myofacial pain
         syndrome, fibromyalgia syndrome.
      Articular rheumatism : osteoarthritis (knee and DIP), rheumatoid arthritis, gouty arthritis,
         spondyloarthropathy (ankylosing spondylitis, psoriatic arthritis, arthritis associated with
         inflammatory bowel disease, and reactive arthritis)
      Connective tissue diseases (SLE, scleroderma, polymyositis/dermatomyositis, MCTD
         and primary vasculitis syndrome)
1.2 To learn how to approach common problems in rheumatology:
          joint pain
          back pain
          muscle pain
          muscle weakness
          regional pain syndrome
          Raynaud's phenomenon
          vasculitis syndrome and CNTD
1.3 To learn how to make specific diagnosis by using fundamental history taking and physical
     examination.
1.4 To learn how to inform the patient properly about their suffering and management plan.
1.5 To learn how to use NSAIDs, DMARDs, corticosteroid, immunosuppressive drugs, muscle
     relaxants, antidepressant and other rheumatic drugs properly.
1.6 To learn how to evaluate drug interaction and awareness of adverse drug reaction.



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1.7 To learn how to give the patient home program for rehabilitation and prevention of
    recurrences properly: quadriceps exercise in OA, exercise in back pain, stretching exercise in
    MPS, intrinsic hand muscle exercise in RA, exercise in AS, ROM vs strengthening exercise

2. Objectives of ward round with on service staff (IPD).
     "Patient evaluation and management in general medicine" “Working as an internist”
  Be skillful in:
       2.1 history taking and physical examination in general medicine and in rheumatology.
       2.2 giving clinical reasoning, data vilification, data collection, and data analysis. How to
              make presumptive diagnosis and differential diagnosis from history and physical
              findings. How to select appropriate laboratory tests according to their specificity,
              sensitivity and predictive value. How to set up priority in investigation and
              management.
       2.3 recognise and handle appropriately emergency or urgent conditions .
       2.3 recognise new occurring problems and giving management properly.
       2.4 perform arthrocentesis appropriately based on indication, anatomical landmark,
              synovial fluid collection, and synovial fluid analysis.

3. Objective of consultation round (IPD).
        “Bed side teaching in general medicine for extern, intern, and residents.”
        3.1 Emphasize on history taking and physical examination in general medicine.
        3.2 Practice in giving clinical reasoning (data collection, data analysis and decision
             making)
        3.4 Understanding thoroughly about management given to the patients and treatment
             evaluation.
        3.5 complete medical record, particulary expert opinion on management plan during
             consultation.
        3.6 making final diagnosis including related conditions according to DRG (ICD 10)

4. Objective of clerkship in AIR clinic (OPD 8)
        “Gain clinical experience in taking care of ambulatory rheumatic patients”


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        4.1 Giving patient care by her/his own, based on theretical knowledge and clinical
             experience learned from “clinical attachment”.
        4.2 Be able to use clinical reasoning in chronic patients’ care: current problems
             evaluation, using appropriate laboratory tests, and create relevant treatment plan for
             his/her own patient.
        4.3 Seeking for expert opinion for any uncertainty.
        4.4 Collect clinical questions from practice for later discussion with staffs at the end of
             working period.
5. Objective of self study.
        “To gain theoretical knowledge of common rheumatic diseases and
        investigation in rheumatology” (see appendix)
6. Objective of Topic discussion.
         “Question and Answer Session”
Free hours for residents to apply the theoretical knowledge studied to clinical practice (knowledge
application)
7. Objective of Scleroderma clinic.
        1. To learn how to cope with chronic rheumatic patients with wide range of clinical
            course and prognosis and without specific effective treatment for cure.
        2. To realise the important of doctor-patient relationship, self help group, self- care
            program, and teamwork among health care personals.
        3. To learn how to evaluate organ involvement in scleroderma by physical examination
            and simple laboratory test.
        3. To able to prescribe drugs used for symptomatic relieve in scleroderma.
        4. Be able to recognize serious complications in SSc (cardiopulmonary and renal) for
            early treatment.
Practical skill during rotation:
1. Arthrocentesis
         1. Suggested reading: (Primer rheumatic disease, ตาราโรคข้อสมาคมรูมาติสซั่ม)
         2. Practical skill:
            - arthrocenteis at common joints



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              - experience local injection therapy, be able to explain indication, contraindication,
                  and limitation.
2. Synovial fluid analysis:
         1. Suggested reading: Synovial fluid analysis:
              ตาราโรคข้อสมาคมรูมาติสซั่มฉบับพิมพ์ครั้งที่ 2; 2547
              (หน่วยโรคข้อและโรคภูมิแพ้), Synovial fluid analysis (Shumacher HR;
              ห้องสมุดศาสตรี)
         2. Clinical skill:
              - synovial fluid analysis and intepretation.
              - Crystal analysis by light microscope.
              - synovial fluid interpretation
3. Plain film interpretation
    1. Common rheumatic diseases : RA, OA, gout, CPPD, septic arthritis, tuberculous arthritis
        including TB spine, ankylosing spondylitis, psoriatic arthritis, SSc, avascular necrosis
    2. Systemic and metabolic bone diseases: hyperparathyroidism, renal osteodystrophy,
        osteoporosis, MM, thalassemia, hemophiliac arthropathy, hypertrophic osteoarthropathy
        (HOA).


Appendix
Recommended topics for reading (topic discussion)
1. Approach to joint pain, back pain, muscle weakness and regional pain.
2. Common arthritis diseases: (categoried by RCPT)
   ระดับ 1 - DJD, RA, Gout, SLE, septic arthritis, AS, ReA & Reiter’s syndrome,
            Psoriatic arthritis, MPS
   ระดับ 2 - TB arthritis, viral arthritis, CPPD, avascular necrosis, polymyositis/
            dermatomyositis, SSc, MCTD, Sjogren syndrome, primary vasculitis
   ระดับ 3 – arthritis associated with inflammatory bowel disease, antiphospholipid
                syndrome
3. autoantibodies in rheumatology
4. Common rheumatic drugs used: implication and side effects:
   - NSAIDs


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    -    DMARDs
    -    Colchicine, Allopurinol, Uricosuric agent
    -    Immunosuppressive agents (cyclophosphamide, azathioprine)
    -    Principal of biological therapy
Facilities provided for self-study
1. Text books (หน่วยโรคข้อและโรคภูมิแพ้)
    1. *ตาราโรคข้อ 2547: สมาคมรูมาติสซั่มแห่งประเทศไทย (ไทย)
    2. * Klipple & Dieppe. Rheumatology. (เน้น clinical approach)
    3. Primer on the Rheumatic Diseases, 12th edition, 2001
    4. Bacterial infection and arthritis: current trends of pathogenesis and management(for basic
       immunology)
    5. Kelley. Textbook of Rheumatology. 2005
    6. Koopman. Arthritis and Allies Condition. 2001
    7. Textbook of Autoimmune disease
2. บทความทางวิชาการ
     1. * Rheumatology for Non-rheumatologist (ไทย, หน่วยโรคข้อและโรคภูมิแพ้)
     2. วารสารโรคข้อและรูมาติสซั่ม (ไทย, หน่วยโรคข้อและโรคภูมิแพ้)
3. Recommended Journal Reading (ห้องสมุดคณะแพทย์)
*1. Best practice in rheumatology (Belliar Rheumatology)
*2. Rheumatic clinic of North America
 3. Current Opinion in Rheumatology
 4. Seminar Rheumatology
4. Recommended web site:
1. www.jointandbone.org (including good lecture)
2. www.rcpt.org (ราชวิทยาลัยอายุรแพทย์) link to www.thairheumatolgy.org
   (สมาคมรูมาติสซั่มแห่งประเทศไทย)
3. http://ratanava.mymaindata.com web bloc อ. รัตนวดี
4. audiovisual:
    - Physical examination in rheumatology (ห้องสมุดคณะแพทย์)
    - Rheumatology for general practitioner (overview, หน่วยโรคข้อและโรคภูมิแพ้)
6. Human skeleton: (ห้องประชุมภาควิชาอายุรศาสตร์)

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posted:12/3/2009
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