Respiratory Medicine – Clinical Clerks

Aim

Provide Clerks with a challenging rotation in Respiratory Medicine.

Objectives

Emphasis will be placed on developing good history taking and physical examination skills and learning to adjust the interview and exam appropriately for patients with respiratory complaints. Clerks will be expected to take a complete occupational history when appropriate.
Clerks will be expected to interview and examine patients presenting with respiratory complaints and develop an appropriate differential diagnosis, evaluation and treatment plan.
Clerks will have the opportunity to learn basic chest x-ray, pulmonary function and arterial blood gas interpretation skills.
 
Specific objectives also include acquiring information about a variety of respiratory conditions including:

  • Evaluation and management of the different forms of Obstructive Lung Disease, particularly COPD and Asthma
  • Evaluation of Restrictive Lung Diseases including neuromuscular weakness, chest wall disorders, and Interstitial Lung Diseases
  • Evaluation of patients with suspected Lung Cancer
  • Evaluation and management of patients with Community acquired Pneumonia
  • DVT/PE
  • Respiratory failure
  • Symptoms and CXR findings suggestive of Tuberculosis
  • Basic Pulmonary Function Interpretation

Chest X-ray Interpretation Skills
  • Given a normal PA and lateral chest X-ray the student will be able to:
    • Identify the three lobes of the right lung and the two lobes of the left lung as well as the fissures that separate these lobes
    • Identify the normal boundaries of the lung, counting ribs anteriorly & posteriorly
    • Identify the cardiac silhouette
    • Identify the ascending aorta, arch of the aorta , and descending aorta
    • Identify the right and left pulmonary arteries
  • Given a patient with a pleural effusion the student will be able to:
    • Interpret a PA and lateral chest X-ray and identify the location of the effusion
  • Given a patient with a pneumothorax the student will be able to:
    • Interpret a PA and lateral chest X-ray and identify the extent of the air in the pleural space
    • Identify a complete lung collapse with shifting of the mediastinal structures indicating a possible tension pneumothorax
  • Given a patient with enlarged hilar structures, the student will be able to:
    • Name three major structures constituting the hila
  • Given a chest X-ray with a mediastinal mass the student will be able to interpret a PA and lateral and:
    • Identify whether the mass is most likely to be in the anterior, middle, or posterior mediastinum
    • List 4 causes of anterior mediastinal mass
  • Given an abnormal x-ray, explain how deviation of the trachea may assist in diagnosis
  • Given a patient with diffuse parenchymal lung disease on chest X-ray, the student will be able to:
    • Differentiate between interstitial disease (lines and dots) and airspace disease (confluence, air bronchograms , silhouette sign)
Pulmonary Function Interpretation Skills

Students will be able to:

  • Define TLC, VC, FRC, and RV
  • Describe (draw a figure of) the relationship between the above volumes
  • Recognize certain common disease patterns on PFT testing including:
    • Obstruction
    • Restriction
  • List at least two diseases that could cause each of the patterns listed:
    • Obstructive
    • Restrictive
    • Isolated reduced diffusion capacity
  • Recognize lung volumes consistent with COPD and that a low DLCO (gas transfer) can be caused by emphysema
  • Correctly interpret spirometry that is normal or shows variable obstruction.
  • Distinguish the pulmonary function pattern of interstitial lung disease from chest wall restriction and muscle weakness.
Arterial Blood Gas Interpretation Skills

Students will be able to:

  • Define terms used in acid/base problems
  • Know the normal values for HCO3, pCO2, pH, H+
  • Explain how an elevated PCO2 causes an acidosis and how a low PCO2 causes an alkalosis
  • Describe the concept of compensation and explain the expected compensation for:
    • Acute respiratory acidosis
    • Chronic respiratory acidosis
    • Acute respiratory alkalosis
    • Chronic respiratory alkalosis
  • Recognize and solve simple and complex (2 or more) acid-base disturbances
  • Given a patient with a simple acid-base disturbance, provide an appropriate differential diagnosis and the most likely cause
Evaluation and Management of Asthma

Given a patient with shortness of breath, cough, and/or wheeze and a normal CXR the student will be able to:

  • Provide a working definition of asthma
  • Take a focused history looking for historical features that suggest asthma including; age of onset, family history, triggers, severity, control, features of occupational asthma, exercise induced asthma, ASA sensitivity, symptoms of allergic rhinitis
  • Perform a physical exam looking for signs of asthma, rhinitis and atopy
  • Order and justify diagnostic tests
  • Advise patients on use of Peak Flow meters, and peak flow monitoring
  • List the medications for symptomatic relief and for control of asthma.
  • Understand the Canadian Asthma Guidelines, Can Respir J 2004
Evaluation and Management of COPD

Given a patient with COPD student will be able to:

  • Provide a working definition of COPD
  • List risk factors for COPD
  • Perform a focused history looking for symptoms suggestive of COPD
  • Perform a focused history to identify triggers and severity on a COPD exacerbation
  • Assess severity of COPD (based on MRC dyspnea scale)
  • Perform a physical exam looking for signs of COPD including signs of a severe exacerbation
  • Order and justify diagnostic tests including EKG, ABGs, CXR
  • Recognize features of hyperinflation on CXR
  • List a differential diagnosis for the causes of an exacerbation
  • Outline an initial management plan for an exacerbation of COPD or for chronic COPD
  • Understand the role of short and long-acting bronchodilators, inhaled corticosteroids and combination therapies in COPD
  • Identify clinical features that indicate patient may need ventilatory support
  • Discuss requirements and benefits of domiciliary O2
  • Recognize the critical role of pulmonary rehab in the management of all COPD patients
  • Understand the Canadian COPD Guidelines, Can Respir J 2003.
Evaluation and Management of Interstitial Lung Diseases

Given a patient with diffuse parenchymal lung / interstitial lung disease (ILD) the student will be able to:

  • Describe the classification of ILD
  • By history, identify important environmental exposures associated with the causes of ILD.
  • Name 5 medications that can cause ILD
  • Justify a plan of investigation, including blood tests, CT scanning and lung biopsy of a patient with dyspnea who has a chest x-ray finding of ILD.
  • Justify a plan of treatment of the common causes of ILD.
  • Recognize that a multidisciplinary approach (involving clinicians, radiologists, and pathologists) is often required to diagnose diffuse parenchymal lung disease.
Evaluation of Patients with a Solitary Pulmonary Nodule or Lung Cancer

Given a patient with an X-ray with a solitary pulmonary or mass the student will be able to:

  • List the two major types of primary bronchogenic neoplasms
  • Categorize the non-malignant causes of lung cancer and provide three examples
  • State factors that determine the probability that a solitary pulmonary nodule is malignant
  • Given a patient who has a solitary nodule or mass on chest x-ray, discuss the radiological investigations, and special procedures which may be useful in the evaluation of the lesion
  • List the three basic components of the TNM staging system
  • Classify small cell and non-small cell lung cancer with respect to:
    • Staging system used; Treatment; and Prognosis
  • List the three primary types of treatment for lung cancer
  • Define paraneoplastic syndrome and list three that are caused by lung cancers
  • Describe the common sites to which primary lung cancers can metastasize or spread
Understanding the Evaluation of Patients with Pleural Disease

Given a patient with an X-ray with a pleural effusion the student will be able to:

  • Name the two different types of pleura and the structures they cover
  • Describe the mechanisms leading to the formation and accumulation of pleural fluid
  • List the clinical manifestations of a pleural effusion
  • Describe Light’s criteria and how they are used clinically
  • Given a clinical scenario, use Light’s criteria to determine whether the pleural fluid represents and exudate or a transudate
  • Using the results derived from pleural fluid analysis (pH, cytology, WBC count and differential, glucose, TG, amylase, Hct) determine the most probable cause of the effusion
  • Describe the diagnostic algorithm for parapneumonic effusion and justify your decision to consider chest tube drainage or to perform a thoracentesis

Given a patient with a pneumothorax the student will be able to:

  • Describe 2 mechanisms of how a pneumothorax can develop
  • Predict what happens to the lung when there is a pneumothorax and explain why
  • Describe the mechanisms and cardiovascular consequences of tension pneumothorax
  • Given a patient with primary, spontaneous pneumothorax, describe the presenting symptoms and typical physical signs
  • Given a patient with a pneumothorax justify a management strategy
  • Describe how a chest tube water seal functions; why it is important in the treatment of pneumothorax and how it indicates if a chest tube can be removed
  • Describe how you would determine whether a chest drain is actually in the appropriate position within the pleural space and if it is indeed patent
Evaluation of Patients with Pulmonary Embolus

Given a patient with a suspected pulmonary embolism the student will be able to:

  • List four (4) common presenting symptoms of pulmonary embolism
  • List four (4) risk factors for pulmonary embolism
  • Given a patient with suspected pulmonary embolism, outline how you would investigate this
  • Given a patient with a confirmed diagnosis of pulmonary embolism, describe the appropriate therapy based on the ACCP guidelines.
Pulmonary Hypertension

Given a patient with a suspected pulmonary hypertension the student will be able to:

  • Describe the expected physical findings of a patient with pulmonary hypertension
  • List four (4) causes of pulmonary hypertension
  • Justify the investigations that should be ordered to confirm a diagnosis and the expected results from those investigations
Evaluation of Patients with Community Acquired Pneumonia or other Pulmonary Infection

Given a patient with suspected pulmonary infection the student will be able to:

  • Suggest an appropriate empiric treatment regimen for community acquired pneumonia

Given a patient with pulmonary infection who is not responding to empiric treatment, the student will be able to:

  • Formulate a differential diagnosis including antibiotic resistance, unusual pathogens, suppurative pulmonary complications, and extrapulmonary septic complications.
  • Describe appropriate investigations for known complications of pneumonia
  • Name the most common pneumonia pathogen in HIV-infected patients with depressed cell-mediated immunity and be able to formulate a diagnosis and management plan for such a patient.
Tuberculosis

Given a patient with suspected tuberculosis the student will be able to:

  • Provide a differential diagnosis for a necrotizing lesion in the upper lobe of the lung
  • List 3 tests or investigations that could be applied to the patient or tissues from a patient to establish the diagnosis
  • Describe the common complications of tuberculosis
  • Given a patient with pulmonary infection suspicious for tuberculosis, defend an infection control strategy for the patient and choose appropriate diagnostic tests
Breathing Disorders During Sleep

Given a patient with suspected breathing problems during sleep the student will be able to:

  • Define obstructive sleep apnea
  • Compare and contrast obstructive and central sleep apnea.
  • Perform a focused history and physical examination; and justify a plan for further diagnostic testing (if necessary) in the setting of suspected obstructive sleep apnea
  • Given a patient with known obstructive sleep apnea, determine whether treatment is necessary, and if so, make specific treatment recommendations.
  • Recognize the risks of initiating CPAP or oxygen in patients with hypoventilation.

Resources

  • Respiratory Inpatient and Consultation services
  • General Pulmonary Outpatient Clinics
  • Inter hospital CXR and Clinical Academic Rounds – Friday AM 0700 – 0900 (Robert Johns Theatre)
  • Local Rounds (Journal club, Clinical Radiologic-Pathology Rounds)

Rotation

The Clerk will be assigned to one of the four acute care sites (Foothills Medical Centre, Peter Lougheed Centre, Rockyview General Hospital, or South Health Campus) for a two week rotation. This is a primarily inpatient-based rotation (ward and consult service), but there are limited opportunities for attending outpatient clinics depending on the site and supervising Respirologist. The Clerk will work closely with the residents, fellows and respiratory team. Attending Respirologists rotate weekly at each site.

Clerks will be assigned inpatients and are expected to see them daily, write progress notes, and to develop a management plan with the help of the Residents and Respirology team. They will also see hospital consultations and review this with staff. There will be opportunities to attend bronchoscopies and other procedures. Clerks are expected to attend Rounds.

There are NO formal call requirements for Clinical Clerks.

For additional information on the rotation, please see webpage, and open the Introduction Letter for the site that you are assigned to, and this will provide further details on the rotation.

Expectation of the Clerks

The students should consider this rotation to be “proactive”. It is expected that the student will be available for all weekdays on both weeks (time away will be allowed for regularly scheduled Clerkship seminars and exams).

Emphasis is placed on acquiring basic clinical skills, including history-taking, physical examination, chest radiology, pulmonary function, and introduction to specialized techniques such as bronchoscopy.

Where to go on Your First Day of the Rotation

SiteDay & TimeLocation
FMCMonday 08:00Doctors Lounge – Meet the entire Team
PLCMonday 08:00Unit 39 and page the Respirologist on call
RGHMonday 08:00Holy Cross Ambulatory Care Centre
(Main Floor) Pulmonary Function Lab Area
(Residents Workroom) – Meet the Entire Team
SHCMonday 08:15Outpatient Pulmonary Diagnostics Unit physician workroom (SHC Outpatient Tower, 6th Floor)

Please note: If the Monday occurs on a STAT holiday (eg Thanksgiving Monday), then arrive on the following Tuesday AM at 0800, and follow the above instructions for RGH, PLC. The exception is the FMC siteon the Tuesday AM at 0800, please attend Medical Grand Rounds, and then head up to Unit 61 (Respirology Ward) and make contact with the respiratory team at 0900.

Evaluations

Please provide your evaluation form to the attending Respirologist on your second week of the rotation. This can be electronic (one45). The attending Respirologist will collate information from your first week Preceptor as well as other members of the team and provide you with an evaluation. Please do not send an evaluation form to both Preceptors. It is your responsibility to remind your attending physician that an evaluation is required.

Elective Rotation Inquiries for Clinical Clerk / Senoir Medical Students From Other University Training Programs

We do accept final year medical students (clinical clerks) from other Accredited Training Programs for a two week elective rotation. We are unable to provide elective rotations for first and second medical students.

Please open “ Clerk Request for Elective Rotation” for more information.

Your duties as a visiting elective Clinical Clerk are identical to our Clerks.

If you have any questions regarding the rotation, please contact the Program Administrator, Vlima Guertin.

Contacts

Program Director
Dr. John Chan, FRCPC
john.chan@ahs.ca

Program Administrator
Renee Ryan
Phone: 403-944-2325
Fax: 403-944-3364
renee.ryan@ahs.ca

We hope that you have an enjoyable Respirology rotation.