PA 739 Family Medicine Syllabus

COURSE CONTACTS: Beverly Speece, MTS, PA-C Director of Clinical Education 1260 HSLC, 750 Highland Ave. Madison, WI 53705 608-265-6723 [email protected]

Lauren Trillo, MMS, PA-C Clinical Faculty 1264 HSLC, 750 Highland Ave. Madison, WI 53705 608-263-5199 [email protected]

Rosa Retrum, MSE Clinical Coordinator 1262 HSLC, 750 Highland Ave., Madison, WI 53705 608-265-6457 [email protected]

PA Program Office 1278 HSLC, 750 Highland Ave., Madison WI 53705 Toll Free: 1-800-442-6698 FAX: 608-265-4973

PA Program Website: http://www.fammed.wisc.edu/pa-program/ PA Program Preceptor Resources: http://www.fammed.wisc.edu/pa- program/preceptors/

COURSE OVERVIEW: The Family Medicine (primary care) clinical rotation is a required, 8-credit module that occurs over a two-month period. The student will predominantly learn in a community- based outpatient setting; yet given the opportunity, any inpatient or nursing home experience is encouraged.

FAMILY MEDICINE PRECEPTORSHIP COURSE GOALS:

1. Provide the student with the opportunity and access to a diverse population of patients and a variety of diseases and injuries involving all body systems across the life span and commonly encountered in outpatient primary care medicine. 2. Support ongoing development and mastery of the student's ability and skill in obtaining a patient centered medical history, conducting a physical examination, recommending diagnostic studies and discussing and recommending treatment plans with the guidance of a preceptor. 3. Provide ongoing interactive opportunities for the student to deepen their knowledge regarding various diagnostic studies used in the evaluation of disease and injury and disease prevention. 4. Provide supervised patient care based opportunities, which foster the development of the student's ability to recommend, select and interpret (where applicable) appropriate diagnostic methods in the evaluation of a patient. 5. Provide clinical based opportunities to continue to develop the student's ability to generate differential diagnoses.

FAMILY MEDICINE PRECEPTORSHIP LEARNING OUTCOMES:

At the end of this eight-week experience students will be able to:

1. Recognize and accurately assess common medical and behavioral diseases and conditions through the application and integration of core medical knowledge (etiology, risk factors, pathophysiology, prevalence, clinical presentation, diagnostic evaluation and interpretation) and the use of evidence based decision making toward the diagnosis, management and treatment of patients encountered in the primary care setting. 2. Recognize and approach the evaluation and initial management of acute presentations commonly seen in the office setting. 3. Recognize and teach the approach to the management of chronic illnesses that are commonly seen in the office setting. 4. Conduct a wellness visit for a patient of any age or gender 5. Recognize and/or provide evidence-based health promotion and disease prevention guidance as well as patient education and counseling. 6. Perform concise, articulate and effective oral case presentations. 7. Recognize and engage in effective on-going (continuity) patient care in an empathetic fashion that demonstrates awareness and sensitivity to diverse religious, cultural, ethnic, gender and sexual orientation patient populations over the course of preceptorship. 8. Recognize, apply and demonstrate effective communication skills. 9. Perform common office based procedures. 10. Effectively and professionally navigate the role and responsibilities as a physician assistant (within the confines of the student role) practicing in a family practice setting.

FAMILY MEDICINE ROTATION -SPECIFIC OBJECTIVES:

These objectives are to guide the student in preparing for the Post Rotation examination by defining areas of content to be emphasized and studied as well as the clinical skills and professional behavior required and expected during this practicum.

Outline to this information is as follows: • Alignment to the PA Core Competencies • Adult Medical Conditions • Health Maintenance/Preventative • Pediatrics • Women’s Health

Alignment to the PA Core Competencies • Interpret the clinical features, differential diagnosis, and

Medical Knowledge management of common acute and chronic medical conditions seen in the ambulatory medical setting.

• Recognize the impact of disease on individuals and societal levels

• Compare preventive strategies for common acute and chronic medical conditions seen in the ambulatory setting, in the clinic, and at the population level

.

• Perform focused histories and physical exams relevant Patient Care to common acute and chronic medical conditions.

• Perform comprehensive wellness exams relevant to patient’s age and comorbidities.

• Formulate treatment plans for common acute and chronic ambulatory medical problems.

• Use test characteristics, predictive values, and likelihood ratios to enhance clinical decision making.

• Distinguish preventive screening tests for individual patients, acknowledging prevalence, risk factors, and outcomes.

• Formulate answerable clinical questions from patient interactions

• Practice life-long learning skills, including the use of Practice-Based Learning

and Improvement evidence based medicine at point of care.

• Differentiate and appraise preventive service guidelines and recommendations from various organizations.

• Identify individual learning goals, and self-assess knowledge and behaviors • Present cases to preceptor in a patient-centered Interpersonal and Communication Skills manner, integrating further testing recommendations, diagnostic probabilities, and evidence-based treatment recommendations as indicated.

• Document clinical encounter in written SOAP note form.

• Establish effective relationships with patients and families.

• Ascertain patient and family beliefs regarding common acute and chronic medical conditions.

• Educate patients and families regarding common acute and chronic medical conditions.

• Demonstrate the process of negotiating management plans with patients, incorporating patient needs and preferences into care.

• Check for patient’s understanding of follow-up plan, including treatments, testing, referrals, and continuity of care.

• Identify community assets and system resources to System Based Practice improve the health of individuals and populations.

• Demonstrate a clinical perspective that recognizes the impact of multiple systems on patient health.

• Recognize and address self-care and personal issues Professionalism that affect one’s ability to fulfill the professional responsibilities of being a physician.

• Assume responsibility, behave honestly, and perform duties in a timely, organized, respectful, and dependable manner.

• Seek, accept, and apply constructive feedback appropriately.

.

Learning Objectives for Adult Medical Conditions

• Know etiology, risk factors, signs and symptoms, diagnostic work up and treatment of the following: (Table 1).

Table 1. Organ Based for Adult Medicine Conditions

Organ Symptoms Conditions Procedural Skills/Other Cardiovasular Chest pain, Hypertension, Coronary artery disease, Interpret EKG SOB, fever, Peripheral vascular disease, Become familiar DOE, Arrhythmias, Endocarditis, with stress test claudication Hyperlipidemia, Hypertriglyceridemia, and echo Angina, Congestive heart failure , Chest pain, Valvular disease

Pulmonary SOP, cough, Asthma, Bronchitis, Chronic Interpret CXR obstructive pulmonary disease, Interpret PFTs Chest pain, Pneumonia, , TuberculosisLung Read peak flows Fever, cancer, Sleep disorders/apnea, Tobacco use/dependence

Gastrointestinal Abdominal Colorectal cancer/colonic polyps, Anal Stool guiac testing pain, fissure, Peptic ulcer disease, Gastritis diarrhea/consti Interpret pation, fever, Gastroenteritis, Pancreatitis, abdominal films N/V, jaundice Inflammatory bowel disease, Appendicitis, Gastrointestinal bleeding, Hemorrhoids,

Bowel obstruction, Viral hepatitis, Jaundice, Cholecystitis/cholelithiasis,Cirrhosis

Giardiasis and other parasitic infections, Hiatal hernia, Gastroesophageal reflux disease Irritable bowel syndrome.

Esophagitis

Orthopedic/ Pain, deformity, Acute and chronic lower back pain, Joint aspirations Rheum swelling, Costochondritis, Fracture care arthralgias Bursitis/tendonitis, Rheumatoid arthritis

Reactive arthritis, Osteoarthritis , Gout, Sprains/strains, Ganglion cysts, Systemic lupus erythematosus, Osteoporosis

Fibromyalgia, Plantar fasciitis, Overuse syndrome

Urology/ Flank pain, Hernias, Cystitis, Pyelonephritis, UA analysis Renal hematuria, Glomerulonephritis, Urince dipstick abdominal Nephrolithiasis, Benign prostatic pain, dysuria hypertrophy, Prostatitis Digital rectal Epididymitis, Gonorrhea, Chlamydia, exam Urethritis, Orchitis, Balanitis, Testicular cancer

Neurology AMS, Vertigo, Syncope, Seizure disorders Perform mini paresthesias, Transient ischemic attack, Cerebral mental exam headache, vascular accident, fever, loss of Alzheimer disease, Parkinson memory, disease, Essential tremor, Bell paralysis, palsy, Dementia, Delirium. dizziness Headaches (cluster, migraine, tension)

Endocrinology Diabetes mellitus, Adrenal insufficiency, Accucheck Cushing disease, Hyperthyroidism Perform a Hypothyroidism diabetic foot exam Hematology Fatigue, fever, Anemia,Leukemia, Thrombocytopenia, easily bruising, Clotting disorders, Lymphoma, bleeding Polycythemia

Psychiatry Highly Major Depressive Disorder, Anxiety SBIRT variable Disorders, Panic Disorder, Social Phobia, Substance Abuse Disorders, Post-traumatic Stress Disorder, Bipolar Disorder, Anorexia nervosa, Bulimia nervosa, Suicide, Spouse or partner neglect/violence Infectious Fever, chills, HIV, Lyme Disease, Influenza, diarrhea, Shigellosis, Salemonella, Meningitis lymphadenop athy, rash, weight loss Dermatology Rash, Dermatitis (eczema, seborrhea), KOH scraping vesicles, Nummular eczema, Dyshidrosis Suturing pruritis, simplex chronicus Punch biopsy erythemia Shave biopsy Drug eruptions, Lichen planus, Pityriasis rosea, Psoriasis, Erythema multiforme, Stevens-Johnson syndrome, Toxic epidermal necrolysis, Bullous pemphigoid,

Acne vulgaris, Rosacea, Actinic keratosis, Seborrheic keratosis, Spider bites, Basal cell carcinoma, Kaposi sarcoma, Melanoma, Alopecia, Onych omycosis, Paronychia, Condyloma acuminatum, Exanthems, Molluscum contagiosum, Verrucae

Cellulitis, Erysipelas, Impetigo, Acanth osis nigricans, Hidradenitis suppurativa, Lipomas/epithelial inclusion cysts, Melasma, Pilonidal disease, Pressure ulcers , Urticaria, Vitiligo F o ll infections r T in e a v e rs ic o lo

EENT Ear pain, ear Pharyngitis/tonsillitis, Acute/chronic discharge, sore sinusitis, Aphthous ulcers, Blepharitis, throat, Conjunctivitis, Dacryocystitis, sneezing, Hordeolum, Labyrinthitis rhinorrhea, eye pain, decreases Laryngitis, Otitis externa, Otitis vision, tinnitus media, Tympanic membrane perforation, Ectropion

Entropion, Corneal abrasion, Corneal abrasion/ulcer, Glaucoma, Hyphema M acular degeneration, Papilledema, Pterygium Retinal detachment,

Retinal vascular occlusion, Retinopathy, Cholesteatoma, Ménière disease, Allergic rhinitis, Epistaxis, Nasal polyps, Peritonsillar abscess, Parotitis,

Sialadenitis

Urgent Care Highly Respiratory variable failure/arrest, Deteriorating mental status/unconscious patient, Allergic reaction/anaphylaxis, Acute abdomen, Burns, Third trimester bleeding , BForeign ites/stin body g s aspiration, Cardiac failure/arrest, Fractures/dislocations, Sprains/strains, Myocardial infarction, Hypertensive crisis, Pulmonary embolus, Pneumothorax,

Ingesting harmful substances (poisonings), Orbital cellulitis

*Based on the PAEA EOR exams

Learning Objectives for Prevention and Health Promotion

• Define primary, secondary and tertiary prevention • Identify risks for specific illnesses that affect screening and treatment strategies • Provide counseling related to health promotion and disease prevention • Discuss an evidence-based, stepwise approach to counseling for tobacco cessation • Find and apply the current guidelines for adult immunizations. • For each core health promotion condition listed in table 2, discuss who should be screened, risk factors and the methods of screening along with developing a health promotion plan for a patient of any age of either gender.

Table 2. Core Health Promotion Conditions for Adults

Cervical Cancer Colon Cancer CAD Depression Breast Cancer Depression Fall risk in elderly patients Intimate partner violence Obesity Osteoporosis Prostate Cancer STIs Substance abuse Type 2 DM

Learning Objectives for Well Child and Adolescents Preventative Care

• Describe the core components of child preventative care-health history, physical examination, immunizations, screening/diagnostics tests, and anticipatory guidance (table 3) • Identify health risks, including accidental and non-accidental injuries and abuse or neglect • Conduct a physical examination on a child • Identify development stages and detect deviations from the anticipated growth and development levels. • Recognize normal and abnormal physical findings in the various age groups • Find and apply the current guidelines for immunizations and be able to order them as indicated. • Identify and perform recommended age-appropriate screenings. • Communicate effectively with children, teens and families.

Table 3. Core Health Promotion Conditions for Children and Adolescents Topic Diet/excercise Family/social support Growth and Development Hearing Vision Lead Exposure Potential for injury Nutritional deficiency Sexual activity Substance abuse

Learning Objectives for Pediatrics Conditions • Know etiology, risk factors, signs and symptoms, diagnostic work up and treatment of the following: (Table 4).

Table 4. Organ-based Pediatric Conditions Organ Symptom Condition Procedural skill/ other ENT Ear pain, ear Otitis media, strep pharyngitis, allergic FB removal discharge, sore rhinitis, hearing impairment, otitis externa, throat, sneezing, epistaxis, acute pharngotonisillitis epiglottis, rhinorrhea oral candidiasis, peritonsillar abscess, Foreign body Pulm Cough, SOB, fever, Pneumonia (bacterial, viral), acute Interpret stridor bronchiolitis, croup, respiratory syncytial CXR virus (RSV), asthma, foreign body, hylaline membrane disease, cystic fibrosis Administer neb treatment Cardiac Chest pain, SOB, Congenital Heart Diseases (atrial septal cyanosis defect, coarctation of the aorta, patent ductus arteriosis, tetraology of fallot, ventricular septal defect), acute rheumatic fever, kawasaki disease, hypertrophic cardiomyopathy Ophth Eye discharge, eye Conjunctivitis, orbital cellulitis, strabismus, Slit lamp pain, decreased corneal abrasion vision GI Abdominal pain, Gastritis, dehydration, appendicitis, colic, Interpret diarrhea/constipat GERD, constipation, pyloric stenosis, abdominal ion, fever, N/V, intussusception, Hirshrung disease, foreign films jaundice body, encopresis, jaundice, duodenal atresia, inguinal hernia, umbilican hernia, niacin deficiencies, vitamin A deficiencies, vitamin D deficiencies, vitamin C deficiencies, lactose intolerance Orthopedics/ Pain, deformity, Nursemaids elbow, slipped capital femoral Fracture Rheum swelling, epiphysis, Osgood-Schlatter disease, care arthralgias Scoliosis, Congenial hip dysplasia, avascular necrosis of the proximal femur, neoplasia, Joint juvenile rheumatoid arthritis reduction Hematology Fatigue, fever, Anemia, bleeding disorders, leukemia, easily bruising, lymphoma, neutropenia, brain tumors, bleeding hemophilia, lead poisoning Endocrine Polyuria, Short stature, hypothyroidism, Urine polyphagia, hyperthyroidism, obesity, diabetes mellitus dipstick heat/cold intolerances Urology/ Abdominal pain, Cryptorchidism, hydrocele, paraphimosis, UA analysis Renal testicular pain, phimosis, testicular torsion, enuresis, dysuria, hematuria hypospadias, vesicourethral reflux, glomerulonephrisits, cystitis Infectious Fever, pain, Atypical mycobacterial disease, pinworms, Disease erythema, cough Epstein-Barr disease, erythema infectiosum, herpes simplex, influenza, mumps, roseaola, rubella, measles, varicella infection, hand- foot-and-mouth disease, pertussis Psychiatry/ (highly variable) Child abuse and neglect, ADD/ADHD, autism Behavioral spectrum disorder, feeding or eating Medicine disorders, depressive disorders, anxiety disorders, disruptice, impulse-control and conduct disorders, suicide Neurology Altered mental Febrile seizures, epilepsy, meningitis, Turner CSF analysis status, fever syndrome, Down syndrome Dermatology Rash, erythema, Dermatitis (diaper, perioral), drug eruptions, KOH pustules, pruritis pityriasis rosea, Stevens-Johnson syndrome, scraping toxic epidermal necrolysis, erythema multiforme, acne vulgaris, lice, scabies, Scabies examthems, verrucae (warts), burns, uticaria, scraping atopic dermatitis, tinea, impetigo, molluscum contagiosum *based on PAEA EOR exams

Learning Objectives for Women’s Health

• Know etiology, signs and symptoms, diagnostic workup and treatment for the following: (Table 5)

Table 5. Gynecological and Obstetrical Conditions

Condition Procedural skill/other

Gynecology Neoplasms Ovarian neoplasms, cervical carcinoma, Perform pap cervical dysplasia, breast cancer, and pelvic -pelvic pain, vaginal endometrial cancer, vaginal/vulvar exam discharge, vaginal bleeding, fever neoplasms Endometrial biopsy

Menstruation Normal physiology, DUB, amenorrhea, dysmenorrhea, menopause, premenstrual syndrome, premenstrual dysphoric disorder

Structural Cystocele, uterine prolapse, rectocele, abnormalities ovarian torsion

Disorders of Mastitis, breast abscess, breast Breast exam the breast fibroadenoma, fibrocystic disease,

Infections Vaginitis (trichomoniasis, bacterial STD cultures vaginosis, candidiasis, atrophic vaginitis), cervicitis (gonorrhea, chlamydia, human Wet prep papilloma virus), herpes simplex, pelvic inflammatory disease, syphilis, chancroid)

Other Contraceptive methods, endometriosis, Contraceptive ovarian cysts, leiomyoma, spouse or counseling partner violence, sexual assault, urinary incontinence, infertility

Obstetrics Prenatal Prenatal diagnosis/care, normal labor FHT care/normal and delivery (stages, duration, -pelvic pain, vaginal pregnancy mechanism of delivery, monitoring), Fundal height bleeding physiology of pregnancy, fetal position, measurement multiple gestations APGAR scoring

Pregnancy Abortion, abruption placentae, ectopic Complications pregnancy, incompetent cervix, placenta previa, gestational diabetes, pregnancy induced hypertension, preeclampsia/eclampsia, molar pregnancy, Rh-incompatibility Labor and Dystocia, fetal distress, premature APGAR score Delivery rupture of membranes, prolapsed Complications umbilical cord, preterm labor, breech presentation

Postpartum Postpartum hemorrhage, endometritis, Care perineal laceration/episiotomy care, normal physiology changes of puerperium

Other Breastfeeding Breastfeeding counseling

*based on the PAEA EOR exams

Recommended Resources

1. Goroll A. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. (Available online through www.hsl.wisc.edu) 2. Rakel R. Textbook of Family Medicine. (Available online through www.hsl.wisc.edu) 3. Fauci A. Harrison’s Principles of Internal Medicine. McGraw Hill. (Available online through www.hsl.wisc.edu) 4. Hamilton RJ. Tarascon Pharmacopoeia. (Pocket or PDA version) 5. Gilbert DN, Chambers HF, Eliopoulos GM. Sanford Guide to Antimicrobial Therapy. (Pocket or PDA version) 6. Lipsky MS and King, MS. Blueprints Family Medicine. Lippincott Williams & Wilkins. 7. Papadakis, MA, McPee S, Rabow MW. Current Medical Diagnosis & Treatment . McGraw Hill.

Recommended Websites Address UpToDate www.uptodate.com Guide to Clinical Preventive http://www.ncbi.nlm.nih.gov/books/NBK16363/ Services American Academy of Family www.aafp.org Physicians (AAFP) American Medical Association www.ama-assn.org/ama/home/index.shtml (AMA) American Academy of Physician www.aapa.org Assistants (AAPA) The Journal of Family Practice www.jfponline.com Family Practice News (Best www.familypracticenews.com/resources/best-practices.html Practices) Patient-Centered Primary Care https://www.pcpcc.org Collaborative AAFP Recommended Health http://www.aafp.org/afp/topicModules/viewTopicModule.htm?to Maintenance Guidelines picModuleId=64 ICD-9 Codes distributed by AAFP http://www.aafp.org/journals/fpm/explore/topic/icd-9.html UpToDate Family Medicine and http://www.uptodate.com/contents/table-of-contents/family- General Practice medicine-and-general-practice

.