PGY1 Inpatient Internal Medicine

Location: Community Memorial Hospital

Educational Purpose:

To learn about the presentation and management of the variety of general medicine and
intensive care patients seen in the inpatient setting. To serve as the primary contact on cases
where multiple specialties are involved. To provide complete care for the patient from
admission through discharge, including completing appropriate, timely documentation and
ensuring communication with the patient’s primary care physician.

Responsibilities/Procedures:

Residents will perform new admissions and consultations and see patients in follow up daily at
Community Memorial Hospital. Residents, under the guidance and direction of the internal
medicine attending, will coordinate the evaluation and initial management of the patient’s
illness. Residents are expected to communicate with all services involved in the patient’s care.
In addition, residents are expected to communicate with ancillary services (Physical
Therapy/Occupational Therapy/Speech Therapy/Social Work/Consultants) to ensure that all
aspects of the patient’s care are being addressed.

Admitting a patient includes writing admission orders, updating the problem list and ensuring
accurate medication reconciliation. The admission history and physical must be documented
within 24 hours of the patient’s admission.

Residents are expected to complete all the appropriate paperwork necessary to facilitate the
patient’s stay in the hospital. This documentation includes, but is not limited to, admission
notes, progress notes, consultation notes, discharge paperwork, and discharge summaries.
Progress notes must be timely and are an integral component of the patient’s care. Residents
must be specific in assessments and plans and ensure that notes are not simply a duplicate of
a note completed on another day.

Ideally, discharges should be completed so that patients can be discharged early in the morning.
This timing improves hospital workflow and patient satisfaction. To facilitate this process,
residents should complete discharge paperwork, follow up appointments, and medication
reconciliation the day prior and review it the morning of discharge with the attending. Discharge summaries are to be done on the day of discharge. If the resident cannot complete the
summary on the day of discharge, they must notify the attending physician.

Medications must be properly reconciled. Discharge medication lists provided to the patient
must match the discharge summary.

Discharge summaries must be reviewed by the attending physician.

Residents are expected to notify the PCP prior to discharge to relay information about the
patient’s hospital stay. Pending studies or future recommendations should be relayed to primary
care provider and be included in the discharge summary.

Residents are required to carry a cell phone with a HIPAA-compliant texting program, in
addition to being available at their assigned work station for staff communication. This
procedure serves as the primary means of communication for staff in regards to patient care.
Residents are expected to return calls within a timely manner to address concerns regarding
patients.

Residents are responsible for Code Coverage during work hours. As such, residents must be in
house during their scheduled shifts.

By the end of the rotation, residents will gain skills in

• Basic interpretation of laboratory data in conjunction with the patient’s clinical
• presentation
• Plain film interpretation
• Basic interpretation of CT scan of brain, chest/abdomen/pelvis

Procedures:

Residents will be exposed to several procedures, with and without ultrasound guidance,
including central venous catheter placement, endotracheal intubation (with and without
Glidescope guidance), arterial line placement, thoracentesis, paracentesis, and lumbar puncture.
Residents are encouraged to assist with or perform procedures under the supervision of internal
medicine faculty or a senior level resident as appropriate to their skill level. The level of
supervision will be determined by previous exposure to the procedure and at the discretion of
the attending physician.

Residents are expected to attend all didactic lectures, Morning Reports and Grand Rounds.

Overall Goals and Objectives:

To develop a basic understanding of the following skills needed to consult and perform
follow up rounds on a general medicine patient:

1. Obtain a focused history surrounding the patient’s clinical presentation.
2. Perform a directed physical examination, which will provide further information in regards to the patient’s clinical presentation.
3. Identify characteristics that are pathognomonic to the disease process.
4. Be able to order and interpret diagnostic testing related to the patient’s presenting complaint/diagnosis.
5. Learn how to avoid unnecessary testing and practice cost conscious medical care.
6. Develop a management plan in regards to the patient’s disease process.
7. Be able to provide recommendations to the primary team caring for the patient in an efficient and accurate manner if the patient is seen in consultation.
8. Be able to recognize and effectively manage the following commonly encountered disease processes as well as other pathology encountered on the rotation:
   1. Hypercarbic and hypoxic respiratory failure
   2. Pneumonia – nosocomial and community acquired with associated complications
   3. Adult Respiratory Distress Syndrome
   4. Transfusion Associated Lung Injury/Transfusion Associated Cardiac Overload
   5. Pneumothorax
   6. Massive hemoptysis
   7. Pulmonary Embolus
   8. Acute exacerbation of congestive heart failure
   9. Cardiogenic shock
   10. Cardiac arrest associated with use of hypothermic protocol
   11. Hypertensive emergency
   12. ST Elevation Myocardial Infarction
   13. Non-ST Elevation Myocardial Infarction
   14. Aortic dissection
   15. GI bleeding (PUD/variceal/diverticular)
   16. Gallbladder disease
   17. Septic shock
   18. Anemia--Blood Loss, TTP, Sickle Cell crisis
   19. Hemorrhagic shock
   20. Complications of neoplastic treatment
   21. Tumor Lysis Syndrome
   22. Peripheral vascular disease
   23. Use of TPA in various settings(PE/PVD/MI)
   24. Electrolyte disorders
   25. Alcohol withdrawal/intoxication
   26. Toxidromes
   27. Endocarditis
   28. Meningitis/encephalitis
   29. Acute kidney injury
   30. Acute CVA
   31. Anoxic encephalopathy
   32. Status Epilepticus
   33. DKA and Hyperosmolar
   34. Hyperglycemic Syndrome
9. Be able to recognize and manage chronic disease states including but not limited to:
   1. Chronic Obstructive Pulmonary Disease
   2. Congestive heart failure
   3. Myocardial infarctions
   4. Diabetes with and without complications
   5. Chronic Kidney Disease
   6. Peripheral Vascular Disease
   7. Substance use
   8. Osteomyelitis/chronic wounds/infections
   9. Hypertension
   10. Dyslipidemia
   11. Malignancy
   12. End of life care
10. Be fully trained in treatment and infection control protocols and procedures (e.g. personal

protective equipment [PPE]) and trained clinically to properly recognize and care for COVID-19 patients.

Teaching Methods:

For each interaction, the resident will spend sufficient time with the patient to perform an
appropriate history and physical examination and then to discuss the case with the internal
medicine faculty member. The learning experience surrounding a patient interaction evolves
from review of history, physical examination, and laboratory results with faculty. The resident
will take direction from faculty, and faculty will provide the resident with references and/or
other learning materials to facilitate their independent study for subsequent review with faculty.
The resident will also learn, under supervision, how to interact not only with patients and
families but also with other physicians caring for the patient.

Evaluation Methods:

Supervising faculty will provide verbal feedback to the resident midway through the rotation
and formally evaluate the resident at the completion of the rotation via New Innovations.
Evaluators will assess the resident’s mastery of core competencies and are encouraged to
comment more specifically on the resident’s performance. Residents may also be evaluated
with Mini-CEXs and 360 evaluations.

Rotation Structure:

1. Residents should contact the lead hospitalist the day prior to determine start time and location.
2. Residents should spend the majority of their time admitting, rounding or consulting on patients in the hospital, with the exception of required conferences or patient-related time elsewhere in the hospital. Downtime should be used for self-study.
   1. Rotations are a “hands-on” learning experience. Residents are the primary treating physician for hospitalized patients and are expected to do a majority of the procedures. Direct observation of residents with real-time feedback is emphasized.
      1. Case-based learning is very effective. Attendings should provide residents with patient-based questions to research and report back.
      2. Residents may be asked to do a short presentation to the group on a pertinent topic.
3. Residents on Swing Shift should aim to see at least 3 admissions per shift.
4. Call and weekend responsibilities TBD by the hospitalist
   1. Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.
   2. Residents have specialty-specific didactics and should be excused in a timely fashion to attend.

Duration:

Resident will be assigned to the CMH Internal Medicine Teaching Service for one month at a
time.

Residents will be assigned to internal medicine faculty attendings.

Educational Materials/references:

Selected Sections from Harrisons

Assigned readings from UpToDate based on patient’s pathophysiology

World Health Organization: How to put on and remove personal protective equipment (PPE)