The RCC takes responsibility for ensuring that all students have experience evaluating the following common signs and symptoms. The Core Signs and Symptoms include back pain, cough, disorders of affect, family/social difficulties, headache, and skin lesions. Students are expected to formulate a differential diagnosis for each using key findings to generate clinical hypotheses and formulate a general evaluation and management plan for each core sign and symptom. Students will log their exposure to these key presenting complaints via a web-based or PDA-based logging system. Students who do not see these presentations in the clinical setting will be required to complete paper or web-based self-instruction modules.

Core Sign Or Symptom: Low Back Pain
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with the symptom of low back pain and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

1. No nerve involvement (non-radicular)
• Mechanical low back or leg pain (97%)
• Idiopathic (lumbar strain or sprain) (70%)
• Disk and facet degeneration
• Osteoporotic compression fracture
• Spondylolisthesis
• Congenital disease (kyphosis, scoliosis, transitional vertebrae)
• Non-mechanical spinal conditions (1%)
• Neoplasia (myeloma, metastases/primary, lymphoma/leukemia)
• Infections (osteomyelitis, septic discitis, abscess, shingles)
• Inflammatory arthritis (associated with HLA-B27)
• Paget disease
2. Nerve root involvement (radicular)
• Herniated disk/Cauda equina syndrome (4%)
• Spinal stenosis (3%)
• Compression fracture (4%), traumatic fracture
• Spinal cord tumor/Peripheral nerve neuropathy
3. Common Sources of Referred Pain - visceral disease (2%)
• Pelvic organs (prostate, endometriosis, PID)
• Renal (stones, infection, abscess)
• Aortic aneurysm, retroperitoneal neoplasm/infection
• Gastrointestinal (pancreatitis, cholecystitis, penetrating ulcer)

• History: Gather data to categorize back pain as musculoskeletal or due to other local or other organ system disease. Determine whether psychosocial distress is amplifying the pain.
• Physical Exam: Perform examination of the back and other anatomic areas that could lead to back pain. Determine whether there is neurological deficit, abnormal bladder, bowel, or sexual function, an inciting event, pain location, radiation, and effect of rest or leg motion.

• Select diagnostic imaging if appropriate to confirm a clinical diagnosis. Be aware or ACR Appropriateness Criteria for Low Back Pain.
• Determine whether there is loss of sphincter tone or urinary retention that may represent a surgical emergency. Determine if signs or symptoms of other emergencies such as leaking abdominal aortic aneurysm exist.

• Communicate an effective plan of management for a patient with pain in the lower back.
• Outline management of acute musculoskeletal back pain without neurological or other abnormality on examination.
• Outline basic management of renal, biliary, gynecological or vascular causes of back pain.
• Select patients in need of interdisciplinary/specialized care.

• Describe the nerve roots that affect reflexes in the lower extremities
• Describe the dermatome innervation of the lower extremity.

• Essentials of Family Medicine, Chapter 37.

• Patient care.
• Readings.
• Online case if benchmark not met.

• Self-assessment.
• Clinical evaluation.
• Written testing.

Core Sign Or Symptom - Cough
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with the symptom of cough and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

• Acute (< 3wks): vascular (pulmonary embolism), infectious (viral URI, viral/bacterial bronchitis, bronchiolitis, croup, sinusitis, pneumonia), cardiac (pulmonary edema), trauma (pneumothorax), exposures (fumes, smoke, cold air), foreign body
• Chronic (>3wks): autoimmune/allergy (asthma, allergic rhinitis, bronchiectasis, post-nasal drip syndrome, chronic sinusitis), neoplasm (lung, mediastinal cancers), substances (tobacco, fumes), gastrointestinal (GERD, aspiration), respiratory (COPD, ILD, cystic fibrosis), cardiac (CHF, mitral stenosis), psychogenic/anxiety, infectious (tuberculosis), medications (ACE-I, beta-blockers), post-infectious

Core Sign Or Symptom: Disorders of Affect
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with a disorder of their affect and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

1. Depressive disorders
• Major depressive disorder
• Dysthymic disorder
• Atypical depression
2. Depression with associations
• Timing (seasonal, postpartum)
• Mood disorder due to medical condition/therapy
• Substance-induced mood disorder
3. Grief and bereavement
4. Depression with manic episode
• Bipolar disorder
• Cyclothymic disorder

• Organic brain diseases
• Endocrine diseases, such as hypothyroid and hyperthyroid diseases
• Malignancy
• Chronic fatigue syndrome
• Medication side effects
• Alcohol & substance abuse

• History: Gather historical data efficiently to identify cues to disorders of affect such as sleep difficulties, fatigue, loss of interest in usual activities or anxiety. In older patients screen for depression as a cause of dementia. (pseudo-dementia) Gather appropriate history to uncover medical conditions associated with depression. Screen for family history and personal history of mania/bipolar disease. Screen for suicidal ideation.
• Physical: Perform a physical exam to uncover clues to possible other medical conditions causing or associated with affective disorders. Use a depression screening tool to both screen for depression and assess effectiveness of treatment.
• Co-morbidities: Screen for associated alcohol and drug use/abuse.

• List and interpret diagnostic tests appropriate to a patient with a disorder of affect.
• Interpret a common depression screening tool
• Identify those patients who are a risk of harm to themselves or others
• Identify those patients who may have underlying bipolar disease

• Communicate an effective initial plan of management for a patient with an affective disorder.
• Use chronic disease management tools including re-administering screening tools to help evaluate attainment of remission.
• Demonstrate knowledge of antidepressive drug treatment (including side effects) and community mental health resources.
• Discuss indications for involuntary detainment of suicidal patients
• Select patients in need of multidisciplinary/specialist care

• Describe the role of neurotransmitters in disorders of affect and how common drug treatment impacts these.

• Essentials of Family Medicine, Chapter 21.

• Patient care.
• Orientation small groups.
• Readings.
• Online case if benchmark not met.

• Self-assessment.
• Clinical evaluation.
• Written testing. SP Case

Core Sign Or Symptom: Family/Social Difficulties
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with family problems and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

• Developmental transitions such as marriage, childbirth, child rearing, adolescence, leaving home, separation and divorce, remarriage, midlife, old age, dying and death can create stress and lead to physical problems.
• Patients who present with family difficulties may also be experiencing them because of a lack of coping skills, alcohol or substance abuse problems or there may be mental health disease within the family contributing to family dysfunction.

• Elicit a history of social, sexual, school or family difficulties that include family of origin, complete family history and stage of Family Lifecycle.
• Obtain additional data from a family conference for information gathering purposes.
• Perform appropriate physical examination for patients presenting with physical complaints.

• Perform an assessment to include depression screening, screening for substance abuse and screen for domestic violence. Utilize depression screening tools and the CAGE questionnaire.

• Determine how to suitably enlist family members in the care of a patient and provide support for caregivers.
• Determine appropriate family counseling programs, community agencies, school based programs for management of social and family difficulties.

• Essentials of Family Medicine, Chapter 1.

• Patient care.
• Readings.
• Online case if benchmark not met.

• Self-assessment.
• Clinical evaluation.
• Written testing. SP Case

Core Sign Or Symptom: Headache
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with the symptom of headache and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

• Describe differential diagnosis for benign headache including migraine, tension, cluster, and secondary causes.
• Describe differential for serious headache including intracranial hemorrhage, intracranial mass, infection and aneurysm.

• History: Obtain detailed history of headache including onset, duration, intensity, frequency, associated symptoms, alleviating and aggravating factors, personal and family history of headaches, neurologic symptoms, trauma, immunosuppression, medications and dietary history.
• Physical Examination: Perform a detailed neurologic examination and cardiovascular examination.

• Identify indications for imaging of the brain. Be aware of ACR Appropriateness Criteria for headache.
• Identify indications for lumbar puncture.

• Outline initial treatment plan for benign headache including lifestyle changes and medications.
• Discuss indications for and medications used for prophylactic treatment of chronic headaches.

• Discuss pathophysiology of migraine, tension, and cluster headaches.

• Essentials of Family Medicine, Chapter 34.

• http://jama.ama-assn.org/cgi/reprint/286/8/960.pdf

• Patient care.
• Readings.
• Online case if benchmark not met.

• Self-assessment.
• Clinical evaluation.
• Written testing.

Core Sign Or Symptom: Skin Lesions
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) presenting with a skin lesion and be able to do the following at the level of a Year 3 medical student:

Discuss the DIFFERENTIAL DIAGNOSIS including:

Inflammatory

• acne – acne vulgaris, acne rosacea, perioral dermatitis
• contact dermatitis – allergic contact dermatitis ( i.e. poison ivy or nickel), irritant dermatitis
• eczematous dermatitis –atopic, nummular, seborrheic, stasis dermatitis
• photosensitivity – dermatomyositis, lupus erythematosus, , photosensitive drug eruption
• psoriasis
• urticaria

• bacterial – cellulites, folliculitis, impetigo
• fungal – candidiasis, dermatophyte infections (tinea), tinea versicolor
• parasitic – lice, scabies
• viral – herpes simplex, herpes zoster, molluscum, warts

• benign – dermatofibroma, nevi, sebaceous hyperplasia, skin tags
• malignant – basal cell carcinoma, squamous cell carcinoma, malignant melanoma

• acquired – cherry angiomas, spider angiomas, spider veins, telangiectasias
• congenital – hemangiomas, vascular malformations

• History: Thorough efficient, focused data gathering to determine the evolution and progression of skin lesions including a history of significant contacts, sun exposure, and family history. Identify patients at high risk for skin cancer.
• Physical Exam: accurately describe skin lesions and eruptions including morphology, location, and distribution. Perform a skin cancer screening exam.
• Co-Morbidities: Identify common dermatological manifestations of systemic disease.

• Culture
• Direct Fluorescent Antibody Test
• KOH prep
• Wet mount
• Skin biopsy

• Communicate an effective plan of management to a patient/their family or caregivers for management of common skin conditions.
• Demonstrate knowledge of classes of topical corticosteroids including potency and vehicles.
• Demonstrate knowledge of common topical and systemic dermatological medications
• Describe common dermatology procedures such as cryosurgery, shave/punch biopsies or elliptical excision

• Demonstrate knowledge of the basic structure of the skin and recognize the adnexal structures including the hair, nails, sebaceous glands and sweat glands.

• Essentials of Family Medicine, Chapter 43.
• Cutaneous Melanoma: Update on Prevention, Screening, Diagnosis, and Treatment- AFP- http://www.aafp.org/afp/20050715/269.pdf

• http://jama.ama-assn.org/cgi/reprint/279/9/696.pdf

• Patient care.
• Readings.
• Orientation photo/didactic
• Online case if benchmark not met.

• Self-assessment.
• Clinical evaluation.
• Written testing. Photo Quiz Post-test.