PULMONARY by chenshu


									                     PRINCE GEORGE’S HOSPITAL CENTER

                     SECTION 17: PULMONARY MEDICINE

This section has been reviewed and approved by the Chief, Division of Pulmonary Medicine
as well as the Program Director, Internal Medicine Residency Program at Prince George’s
Hospital Center.

________________________                    ______________________________
Chief, Division Of Pulmonology          Program Director, Residency Program

I. Overview

   Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper
   airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in
   neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura, and
   airways; pulmonary vascular disease and its effect on the cardiovascular system; and
   detection and prevention of occupational and environmental cause of lung disease.
   Other specialized areas include respiratory failure and sleep-disordered breathing.

   By the end of their training in internal medicine, residents should be able to evaluate and
   manage cough, dyspnea, fever with infiltrates, mass or nodule on the chest radiograph,
   pleurisy, and pleural effusion. He/she should be able to diagnose and manage patients
   with common respiratory infections: initiate the diagnostic evaluation of respiratory
   neoplasm; and manage the initial approach to patients with respiratory failure, including
   those in intensive care units.

   With more hospitalist jobs requiring interninsts to manage patients on ventilators on
   medical floors or intensive care units, residents during their rotation should obtain a
   working knowledge of this subject. The pulmonary specialist will usually assist internist
   for diagnostic procedures and complicated conditions such as advanced respiratory

II. Principle Teaching Methods

   This consists of frequent encounters with the medicine residents and making that person
   accountable for performance. It primarily consists of bedside rounds conducted most
   days of the week, a s well as in radiology. Here most of the teaching will be carried out.
   The residents will also observe performance of pulmonary function tests in the PFT
   laboratory and learn interpretation of the results. They will also observe special
   procedures like bronchoscopies done on the patients that they are following. The
   residents will also get a working knowledge of mechanical ventilators through rounds
   and didactics focusing on management of hospitalized patients requiring ventilator

   The resident will have frequent interaction with their supervising attending and rounds
   will include short 15-30 minute discussions on current medical topics driven by patient
   encounters, initiated by the residents and completed by the attending physician on most
    days of the week. Latest information dealing with the topic as provided by literature
    search and pertinent articles made available to the residents.

    During the rotation the residents will outpatient Pulmonary office practice three half days
    a week with Dr. Murthy or Dr. Steinberg. Residents must print out a copy of the
    ‘Pulmonary Attendance Sheet’ from the end of this section and have it signed for each
    outpatient day. The residents will also round with Dr. Boyce on hospitalized patients on
    mechanical ventilation and learn about different ventilator modes and management of
    patients and acute and chronic ventilation. Residents must have their attendance taken
    during these rounds. The residents must submit their Attendance Sheet with the
    program coordinator as a requirement for successful completion of the rotation

    During the rotation the resident must also analyze a minimum number of diagnostic tests
    with the staff pulmonologist. The logsheet at the end of this section lists the tests and
    their minimum number they must interpret for the month. The residents are required to
    view X Ray and CT films with the attending as well as interpret ABG and PFT results.
    They are also required to review all Lung biopsy slides with the pulmonary attending
    physician in pathology irrespective of whether the patient is on staff service or not. This
    is to allow residents to review pathology report, learn indications for bronchoscopy and
    lung biopsies as well as learn about the disease process of the particular case.
    Residents must print a double-sided Pulmonary Logsheet and have it signed by the
    attending as they complete each requirement. Residents must submit a completed copy
    to the program coordinator to get credit for the rotation.

III. Strengths and Limitations

    The residents will be exposed to a broad range of clinical problems typical of a
    community-based practice with emphasis on inpatient illnesses and care. The teaching
    faculty for the Department of Pulmonology will be committed to teaching and being a
    strong role model to the residents. They will supervise the residents on consults,
    interpreting results of radiographic and pulmonary function studies, bedside procedures
    like thoracentesis, ventilator management and make residents familiar with indication of
    special procedures like bronchoscopy, VATS.

    For patients with unusual clinical problems the care may require transfer to tertiary
    referral center. The residents are encouraged to gain outpatient experience in the
    subject by shadowing the attending in their private office. Patients in the continuity clinic
    at Glenridge also offer learning opportunities. The resident can also utilize the
    opportunity to learn regarding cardiopulmonary rehabilitation from patients who are
    status post cardiac bypass surgery.

IV. Goals and Objectives
    Legend of Learning Activities
    Learning Venues:
    1. Direct patient care/ consultation
    2. Attending rounds
    3. Morning report and noon conference
    4. Core lecture series
    5. Self study

    Evaluation methods
       A.   Attending rounds on consult patients
       B.   Attending evaluation of PFT, ABG and radiologic interpretation skills
       C.   Direct Observation
       D.   Nurse’s evaluation
       E.   In-training examination

Competency: Patient Care                                   Learning Venues          Evaluation Methods
Interview patients more skillfully, gathers accurate and   1, 2, 3, 4               A, B, C, D
essential information with emphasis on pulmonary
Examine patients more skillfully with competent and        1, 2, 3, 4               A, B, C, D
complete observation of normal and abnormal signs
with emphasis on disorders of the pulmonary system
Define and prioritize patient’s medical problems           1, 2, 3, 4               A, B, C, D
Generate and prioritize differential diagnoses with        1, 2, 3, 4               A, B, C, D
appropriate testing and therapeutics
Develop rational, evidence-based management                1, 2, 3, 4               A, B, C, D
Competency: Medical Knowledge                              Learning Venues          Evaluation Methods
Expand clinically applicable knowledge base of the         ALL                      A, B, C, E
basic and clinical sciences underlying the care of
medical service patients, both out and inpatients with
emphasis on pulmonary disorders.
Access and critically evaluate current medical             ALL                      A, B, C E
information and scientific evidence relevant to patient
Competency: Practice-Based Learning and                    Learning Venues          Evaluation Methods
Identify and acknowledge gaps in personal knowledge        ALL                      A, B, C, E
and skills in the care of hospitalized and out patients
Develop and implement strategies for filling gaps in       ALL, meet with           A, B, C, E , attendance
knowledge and skills and minimize errors                   Program Director         sheet
Competency: Interpersonal Skills and                       Learning Venues          Evaluation Methods
Communicate effectively with patients and families,        1,2,3                    A, B, C, D
with particular emphasis on explanation of complex
and multi-system illness and the testing required to
confirm diagnostic possibilities
Communicate effectively with physician colleagues at       1,2,3                    A, C
all levels with appropriate consultation when needed
Present patient information concisely and clearly,         1, 2                     A, C
verbally and in writing. Adhere to confidentiality
Competency: Professionalism                                Learning Venues          Evaluation Methods
Demonstrate respect, compassion, integrity and             1,2,3                    A, C, D
altruism towards patients, families, colleagues, and all
members of the health care team
Demonstrate sensitivity to confidentiality, gender, age,   1,2,3                    A,C,D
cultural differences and disabilities
Competency: Systems-Based Practice                         Learning Venues          Evaluation Methods
Understand and utilize the multidisciplinary resources     ALL                      A,C,D
necessary to care optimally for hospitalized and out
patients and the limitations of various practice
Collaborate with other members of the health care       1,2                  A,C,D
team to assure comprehensive patient care
Use evidence-based, cost-conscious strategies in the    1,2,3,4              A,C,D
care of hospitalized and outpatients

   V. Educational Content

       A. Airway Diseases
          1) Diagnosis and management of:
              Asthma
              Bronchiectasis
              Bronchitis
              Chronic obstructive pulmonary disease
              Upper airway obstruction- initiate management
          2) Order appropriate tests and interpret results of:
              Complete pulmonary function tests (spirometry, measurement of lung
                volume, diffusing capacity, flow volume loop)
              Cardiopulmonary stress test
              Pre-operative pulmonary clearance in lung reduction surgery

       B. Intensive care unit condition
          1) Identify and initiate management of
               Acute Respiratory Distress Syndrome
               Ventilator associated Pneumonia
               Tension Pneumothorax
               Pulmonary embolism
               Pulmonary hypertension
          2) Order appropriate tests and interpret results of:
               Swan ganz catheter reading
               Chest X Ray
               CT thorax
               Ventilation perfusion scan
               Arterial blood gases

       C. Congenital Lung Disease
          1) Understand the diagnostic criteria, long term complications and management of:
              Alpha1, antitrypsin deficiency
              Cystic fibrosis
              Dysmotile cilia syndrome
          2) Criteria for transplantation

       D. Infection
          1) Diagnosis and initial management of
               Atypical mycobacteria
               Empyema
               Lung abscess
          Pneumonia (Community-acquired, nosocomial, In           immunosuppressed
         Pulmonary mycoses
         Tuberculosis
     2) Order and interpret results of:
         PPD in outpatient, inpatient and nursing home setting
         Sputum cultures and stains
         Chest X rays and other imaging studies

E. Interstitial Disease
        Collagen vascular disease
        Drug-induced
        Eosinophilic pneumonia
        Hypersensitivity
        Idiopathic pulmonary fibrosis
        Sarcoidosis

F. Neoplasm
   1) Know the diagnostic work up and management of
       Lung cancer – all types
       Mediastinal mass
       Solitary pulmonary nodule
   2) Know indications for ordering and interpreting results of:
       PET scan
       CT scan
       Chest x ray
       Bronchoscopy with FNA biopsy, BAL
       Cytology, pathology of lung and pleural biopsy specimens
       Diagnostic studies for venous thrombosis
       Mediastinoscopy, mediastinotomy

G. Occupational Disease
       Asbestos-related
       Occupational asthma
       Pneumoconiosis

H. Pleural Disease
       Malignant effusion
       Non-neoplastic pleural effusion

I.   Prevention
         Avoidance of respiratory irritants, allergens
         Immunization
         Pulmonary carcinogens (radon, passive smoking)
         Smoking cessation

J. Vascular Lung Disease
   1) Understand the diagnosis and management of patients with:
       Pulmonary Hypertension
          Cor pulmonale
      2) Understand the indications and interpreting results of
          2 D echocardiograms and TEE
      3) Criteria for transplant and its complications

   K. Sleep-disordered breathing
          Know indications and Interpretation of results of sleep study to diagnose
            central and obstructive sleep apnea
          Appropriate management including interpretation of titration studies

VI. Recommended Readings

   Residents are encouraged to read the Pulmonary section of the MKSAP during their
   rotation as well as read articles using MDConsult and Up To Date on a case by case
   basis. Other recommended readings are as follows:

   A. COPD
      1) Soto, FJ and Varkey B. Evidence-based approach to acute exacerbations of
         COPD. Current Opinion in Pulmonary Medicine 9:117-124, 2003.
      2) Sutherland ER and Cherniack R. Management of chronic obstructive pulmonary
         disease. New England Journal of Medicine 350:2689-97, 2004.

   B. Pneumonia
      1) File TM. Community-acquired pneumonia. Lancet 362:1991-2001, 2003.
      2) Niederman MS, Mandell LA, Anzueto A et al. Guidelines for the management of
         adults with community-acquired pneumonia. Diagnosis, assessment of severity,
         antimicrobial therapy, and prevention. American Journal of Respiratory and
         Critical Care Medicine. 163(7):1730-1754, June 2001.

   C. Asthma
      1) Siwik JP, Nowak RM, and Zoratti EM. The evaluation and management of acute,
         severe asthma. Medical Clinics of North America 86(5): 1049-71, 2002.
      2) FitzGerald M. Acute Asthma (Extracts from "Clinical Evidence"). BMJ 323(7317):
         841-5, October 13, 2001.
      3) Mathur SK. Asthma: diagnosis and management. Med Clin North Am - 01-Jan-
         2006; 90(1): 39-60

   D. Pulmonary Function Tests
      1) Crapo RO. Pulmonary-function testing. New England Journal of Medicine.331
         (1): 25-30, July 7, 1994.
      2) Celli BR. The importance of spirometry in COPD and asthma: Effect on approach
         to management. Chest. 117(2 Suppl): 15S-19S, February 2000.

   E. Thromboembolic Disease
      1) Ramzi DW and Leeper K. DVT and pulmonary embolism: Diagnosis. American
         Family Physician 69:2829-36, 2004.
      2) Ramzi DW and Leeper K. DVT and pulmonary embolism: Treatment and
         prevention. American Family Physician 69:2841-8, 2004.
     3) Bauer KA. The thrombophilias: Well-defined risk factors with uncertain
        therapeutic implications. Annals of Internal Medicine. 135(5): 367-73, September
        4, 2001.
     4) Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh
        ACCP Conference on Antithrombotic and Thrombolytic Therapy. Harry R. Büller,
        Giancarlo Agnelli, Russel D. Hull, Thomas M. Hyers, Martin H. Prins, and Gary E.
        Raskob. Chest 126: 401S-428S.

F.    Pleural Disease
     1) Light RW. Pleural effusion. NEJM. 346:1971-77, 2002.
     2) Sahn SA, Heffner JE. Spontaneous pneumothorax. New England Journal of
         Medicine. 342(12): 868-74, March 23, 2000.
     3) Maskell N A and Butland R J A, BTS guidelines for the investigation of a
         unilateral pleural effusion in adults. Thorax 2003; 58 (Suppl 2): ii8-ii17.

G. Interstitial Lung Disease/Sarcoidosis
   1) Gross TJ, Hunninghake GW. Idiopathic pulmonary fibrosis. New England Journal
       of Medicine. 345(7): 517-25, August 16, 2001.
   2) Baughman RP, Lower EE, and duBois RM. Sarcoidosis. Lancet 361:1111-18,
   3) Collard HR, King TJ, Demystifying Idiopathic Interstitial Pneumonia, Arch Intern
       Med 2003; 163:17-29.
   4) Baughman RP. Pulmonary Sarcoidosis. Clin Chest Med - 01-Sep-2004; 25(3):

H. Sleep Apnea
   1) Masood A, Phillips B. Sleep apnea. Current Opinion in Pulmonary Medicine. 6(6):
      479-84, November 2000.
   2) Herer B, Roche N, Carton M et al. Value of clinical, functional, and oximetric data
      for the prediction of obstructive sleep apnea in obese patients. Chest. 116(6):
      1537-44, December 1999.
   3) Strollo PJ Jr., Rogers RM, Obstructive sleep apnea. N Engl J Med. 1996 Jan 11;
      334(2): 99-104.

I.   Tuberculosis
     1) Small PM, Fujiwara PI. Management of tuberculosis in the United States. New
        England Journal of Medicine. 345(3): 189-200, July 19, 2001.
     2) Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide
        for latent tuberculosis infection, and revisions in American Thoracic Society/CDC
        recommendations--United States, 2001. Morbidity and Mortality Weekly Report.
        50(34): 733-5, August 31, 2001.

J. Lung Transplantation
   1) Arcasoy SM, Kotloff RM. Lung transplantation. New England Journal of Medicine.
      340(14): 1081-91, April 8, 1999.
   2) Levine SM, Angel LF. The patient who has undergone lung transplantation:
      Implications for respiratory care. Respir Care. 2006 Apr; 51(4):392-402.
   3) Alexander BD, Tapson VF. Infectious complications of lung transplantation.
      Transplant Infectious Disease. Vol 3 (3) 128-137, Sep 2001
K. Diagnosing Lung Cancer
   1) Ost D, Fein AM, Feinsilver SH, The Solitary Pulmonary Nodule, N Engl J Med
      2003; 348:2535-42.
   2) Hensing TA, Clinical evaluation and staging of patients who have lung cancer.
      Hematol Oncol Clin North Am - 01-Apr-2005; 19(2): 219-35

L. Chronic Cough
   1) Irwin RS, Madison JM, The persistently troublesome cough, Am J Respir Crit
      Care Med 2002, 165(11): 1469-74.
   2) Evidence-Based Clinical Practice Guidelines: ACCP Diagnosis and
      Management of Cough Executive Summary, Chest 2006, 129:1S–23S
                                PRINCE GEORGE’S HOSPITAL CENTER
                             INTERNAL MEDICINE RESIDENCY PROGRAM

                                         PULMONARY LOGSHEET
       RESIDENT NAME______________________________________________

        PGY LEVEL_______________               ROTATION MONTH_____________
* Any lung biopsy during the month, irrespective of whether the patient is staff or not, must be personally
reviewed by resident under direct supervision of attending physician, (no minimum # requirement)
   LABORATORY            Lung Biopsy*/ VQ        CXR and CT
                                                                           PFT                   ABG
      DATA                    Scans                scans

     Interpretation of
    result by resident
   management plan)
       Comment by
 supervising attending
  (correct/not, missed
       findings etc)
  attending & DATE


     Interpretation of
    result by resident
   management plan)
       Comment by
 supervising attending
  (correct/not, missed
       findings etc)
  attending & DATE

     Interpretation of
    result by resident
   management plan)
       Comment by
 supervising attending
  (correct/not, missed
       findings etc)
  attending & DATE
      RESIDENT NAME:____________________________________________

 LABORATORY             Sputum stain and   CXR and CT
                                                        PFT        ABG
    DATA                     culture         scans

    Interpretation of
   result by resident
  management plan)
      Comment by
supervising attending
 (correct/not, missed
      findings etc)
 attending & DATE

    Interpretation of
   result by resident
  management plan)
      Comment by
supervising attending
 (correct/not, missed
      findings etc)
 attending & DATE


    Interpretation of
   result by resident
  management plan)
      Comment by
supervising attending
 (correct/not, missed
      findings etc)
 attending & DATE


RESIDENT NAME______________________________________________

PGY LEVEL_______________      ROTATION MONTH_____________

                                                         SIGNATURE OF


RESIDENT NAME______________________________________________

PGY LEVEL_______________      ROTATION MONTH_____________

                                                         SIGNATURE OF

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