The RCC takes responsibility for ensuring that all students have experience evaluating the following common clinical issues. The RCC core clinical issues include allergies, asthma, depression/anxiety, diabetes mellitus, hypercholesterolemia/dyslipidemia, hypertension, obesity, skin infection, social abuse, sprain or strain, preventive health, and upper respiratory tract infection. Students are expected to identify key findings and comorbidities related to each disease and to formulate a general evaluation and management plan for each. Students will log their exposure to these key diseases via a web-based or PDA-based logging system. Students who do not see these problems in the clinical setting will be required to complete paper or web-based self-instruction modules.

Clinical Problem – Allergies (Allergic Rhino-conjunctivitis & Urticaria)
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with allergic rhinitis, conjunctivitis or urticaria (Hives) and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Elicit a detailed history including timing of symptom/lesion onset/duration, and identification of precipitants
• Identify common allergens and their possible effects on susceptible children and adults.
• Physical examination: Perform and appropriate exam of the conjunctiva, ENT chest and skin. Recognize nasal polyps and classic urticarial lesions.
• Comorbidities: Assess if patient is asthmatic. Determine if symptoms may be indicative of systemic disease. Identify serious conditions such as anaphylaxis.

• List and interpret diagnostic tests which are key in the processes of exclusion, differentiation, and diagnosis of allergic conditions:
• Indicate those conditions where laboratory investigation is indicated.
• List cost effective use of tests designed to identify allergens.
• Interpret results so as to differentiate the allergic from the non-allergic individual.

• Communicate an effective initial plan of management for a patient with allergies, including identification and discontinuation of offending trigger and pharmacological therapy.
• Outline the basic emergency management of a patient with anaphylaxis.
• Discuss skin testing in allergic individuals.
• Outline the immediate and long-term management of the child or adult with allergies including education and counseling for the patient, family, school, and the community.
• List common medications used in the management of allergies (along with their side effects).
• Contrast first generation and second generation H1 receptor antagonists
• List indications for steroids.
• Select patients in need of multidisciplinary/specialist care

• Outline the different cellular/immune mediators involved in early & late phase allergic reactions including mast cells, histamine, leukotrienes, cytokines and other mediators.
• Outline the effects of therapy on specific elements of the allergic process.

• Essentials of Family Medicine, Chapter 19.
• “Diagnosing Rhinitis: Allergic vs. Nonallergic”- AFP- http://www.aafp.org/afp/20060501/1583.pdf

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

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

Clinical Problem – Asthma
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with asthma and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Elicit a detailed symptoms history about intermittency, seasonal waxing and waning, nocturnal episodes, exacerbation on exposure to exercise, cold air, allergens, air pollutants, smoking history, or upper respiratory tract infections.
• Physical: Perform an appropriate physical exam to assess evidence of degree of airflow obstruction and oxygenation.
• Comorbidities: Assess the patient for other atopic conditions and cardiovascular complications of airflow obstruction or concurrent cardiovascular disease

• List and interpret diagnostic tests which are important in the processes of exclusion, differentiation, and diagnosis of asthma.
• Utilize spirometry and FEV1 to quantify severity of airway narrowing.
• Select and interpret diagnostic imaging to detect complications of asthma and to exclude alternative diagnoses.
• Demonstrate knowledge of National Asthma Guidelines
• Discus the use of peak flow monitoring in the chronic care of asthma patients.
• List indications for allergy testing for asthma.
• Identify those patients in need of hospitalization

• Communicate an effective action plan for managing a patient with asthma
• Utilize the concepts of chronic disease management to care for an asthmatic patient.
• List common medications used in asthma (along with their side effects)
• Outline an initial plan of management for a patient with an exacerbation of asthma in the ambulatory setting.
• Select patients in need of multidisciplinary/specialized care.

• Outline the role of different types of cells in the chronic inflammatory condition of the airways associated with asthma (mast cells, eosinophils, T cells).
• Explain how the pharmacological interventions used in this disease relate to the cells identified above.

• Essentials of Family Medicine, Chapter 19.
• CCGC Asthma Guideline summary. Provided at orientation.

• http://jama.ama-assn.org/cgi/reprint/284/17/2225.pdf

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

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

Clinical Problem – Depression/Anxiety
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with depression or anxiety and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Perform a history to elicit the symptoms of depression (depressed mood, loss of interest in all activities, change in weight/appetite, sleep, energy, concentration, feeling of hopelessness, worthlessness or guilt, recurrent thoughts of suicide, increase in somatic complaints or withdrawal from others), anxiety (excessive worry about events which is out of proportion to the impact of the event, discrete period of intense fear, recurrent panic attacks, along with cardiopulmonary, neurological, psychiatric or other medical symptoms) and precipitating life stressors. Determine whether a general medical condition is present, use or abuse/dependence of alcohol, caffeine or drugs (or withdrawal) and gather family history of psychiatric disease. Determine how long these symptoms have been present.
• Physical Exam: Perform a focused exam to identify physical conditions that could present as depression or anxiety.
• Comorbidities: Identify those patients with chronic diseases at risk of depression. Identify coexisting thyroid or other health problems, alcohol or drug problems.

• Select patients who require further investigation for medical condition or drugs that affect mood (e.g., thyroid function, toxicology screen, electrolytes, etc.).
• Use screening tools to assist in the diagnosis and to document response to treatment/remission.
• Identify those patients who are suicidal or require hospitalization

• Communicate an effective initial plan of management for a patient with anxiety or a mood disorder.
• Use chronic disease management tools including re-administering screening tools to help evaluate attainment of remission.
• Outline and describe treatment under categories of medications, physical treatment, and psychological treatment and/or community mental health resources.
• Select patients in need of multidisciplinary/specialized care.

• Explain current knowledge of the pathophysiology/neuro-physiology of anxiety/depression and how treatment affects these mechanisms.

• Essentials of Family Medicine, Chapter 21.
• CCGC Guideline material provided in clerkship syllabus.

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

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

Clinical Problem – Diabetes Mellitus (Types I & II)
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with diabetes mellitus and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Perform a history to uncover symptoms of diabetes mellitus and associated complications. Elicit a family history of DM.
• Physical exam: Perform a physical exam to determine if there are signs of DM complications or co morbid conditions.
• Comorbidities: Elicit a personal or family history of hypertension, hyperlipidemia, obesity or cardiovascular disease

• Select and interpret diagnostic tests for diagnosis of diabetes mellitus and its complications.
• Discuss HbA1c and glycemic monitoring.
• Discuss urine microalbumin and nephropathy diagnosis. Diagnose diabetic ketoacidosis, severe hyperglycemia, and hyperosmolar state; determine the precipitating causes.
• Discuss criteria used to determine if hospitalization is indicated

• Communicate an effective initial plan of management for a patient/caregiver for hyperglycemia:
• Outline the management of ketoacidosis, hyperosmolar state, and severe hypoglycemia.
• Outline appropriate immediate and chronic disease management of diabetes mellitus, including exercise, diet, blood pressure control and primary and secondary prevention of complications, both micro and macrovascular.
• List oral drugs and insulin formulations used in the management of DM (including side effects)
• Conduct education and counseling to patients with diabetes mellitus and their families, including lifestyle modifications, and primary and secondary preventive strategies for the complications of the disease (role of ACEI and ARBs, lipid control, BP control, foot care and eye care).
• Select patients in need of multidisciplinary/specialized care.

• Contrast the mechanism of hyperglycemia in Type I & Type II diabetes mellitus.
• Compare the mechanism of action of insulin to that of various classes of oral hypoglycemic agents.

• Section on Diabetes in the clerkship syllabus.
• CCGC Guidelines provided at orientation.

• ADA Standards for DM Care -http://care.diabetesjournals.org/cgi/reprint/29/suppl_1/s4.pdf

• Patient care.
• Small group learning at orientation.
• Readings.
• Online case if benchmark not met.

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

Clinical Problem – Hypercholesterolemia / Dyslipidemia
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 lipid disorder and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Elicit a detailed history to identify a family history of lipid disorders and CVD and those patients with secondary causes for their lipid abnormalities.
• Physical exam: Conduct an appropriate exam to identify skin manifestations of lipid disorders and evidence of associated cardiovascular complications.
• Comorbidities: Identify patients with CVD

• Select patients to test and interpret the results of a fasting lipid panel.
• Stratify patients by their risk for subsequent development of CAD for consideration of lifestyle/drug therapy.
• Use decision tools in the stratification process.

• Communicate an effective plan of management for a patient with abnormal serum lipids:
• Identify threshold values for treatment and goal LDL cholesterol levels depending on a patient's underlying risk.
• Conduct education and lifestyle modification for patients and their families
• List common drugs used to treat lipid disorders (include side effects)
• Select patients in need of multidisciplinary/specialized care.

• Describe dietary fat and cholesterol absorption, transport, and metabolism; list major circulating lipoproteins.
• Outline the basic aspects of the pathogenesis of atherosclerosis including factors such as endothelial dysfunction, dyslipidemia, inflammation, tissue factor, etc.
• Explain the antiatherogenic effect of HDL by reverse cholesterol transport
• Describe the mechanism of action of drugs that have been shown to lower cholesterol levels (e.g., HMG CoA reductase inhibitors, fibrates, resins, niacin, cholesterol absorption inhibitors).

• Section in the clerkship syllabus.

• ATP III Guide-http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3xsum.pdf

• Patient care.
• Small group learning at orientation.
• Readings.
• Online case if benchmark not met.

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

Clinical Problem – Hypertension
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with hypertension and be able to do the following at the level of a Year 3 medical student:

Clinical Task (Key Findings)

• History: elicit a personal and family history of hypertension and cardiovascular disease.
• Physical: perform physical exam including blood pressure measurement.
• Comorbidities: identify major CVD risk factors including obesity, dyslipidemia, diabetes, smoking, and physical inactivity.

• Identify criteria for diagnosis of hypertension.
• Interpret results of blood pressure measurements.
• Identify secondary causes of hypertension.
• Stratify patients by their stage of hypertension.

• Outline an effective plan of management for a patient with hypertension.
• Identify goal blood pressure levels for patient’s underlying risk.
• Select appropriate medication, if indicated.
• List common adverse effects expected with usual anti-hypertensive medications.
• Outline plan for education and counseling with patients and their families regarding lifestyle modification. Review DASH diet guidelines, weight reduction, lowering sodium intake, tobacco cessations, increasing physical activity, and consuming alcohol in moderation.

• Explain current knowledge of the pathophysiology of hypertension and how treatment affects these mechanisms.

• Section in the clerkship syllabus.
• JNC 7 Summary in AFP- http://www.aafp.org/afp/20030715/practice.html

• JNC 7 Report- http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

• Patient care.
• Small group learning at orientation.
• Readings.
• Online case if benchmark not met.

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

Clinical Problem – Obesity
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with obesity and be able to do the following at the level of a Year 3 medical student:

Clinical Task

• History: Elicit a detailed personal and family history of obesity; elicit a diet and physical activity history.
• Physical: Perform a physical examination including Body Mass Index (BMI) and waist circumference.
• Comorbidities: Assess patient’s absolute risk status for the presence of CHD, other atherosclerotic diseases, type 2 diabetes, and sleep apnea. Identify other risk factors including physical inactivity and patient motivation.

• Diagnose overweight or obesity and disease risk utilizing BMI and waist circumference measurements.
• Select appropriate treatment options for BMI category. For BMI >30-39, discuss pharmacotherapy options. For BMI >40, discuss bariatric surgery options.
• Select appropriate diagnostic tests for presence of comorbidities.

• Conduct an effective plan for weight management with the initial goal of weight loss therapy to reduce body weight by 10%.
• Outline an appropriate meal plan to reduce calorie intake by 500 kcals/day.
• Outline an appropriate physical activity plan to increase energy expenditure by 250 calories/day.
• Outline appropriate long-term management of obesity including primary and secondary prevention of complications.
• Conduct education and counseling with patients and their families, including lifestyle modification.
• Refer to other health care professionals or other reputable weight management resources within the community.

• Explain current knowledge of the pathophysiology of overweight and obesity and how treatment affects these mechanisms.

• Essentials of Family Medicine, Chapter 48, pages 783-801
• National Obesity Guidelines- http://www.nhlbi.nih.gov/guidelines/obesity/ob_exsum.pdf

• Patient care.
• Small group learning at orientation.
• Readings.
• Online case if benchmark not met.

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

Clinical Problem – Skin Infections
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 skin infection and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Through efficient, focused, data gathering identify the presenting features subsequent course of the infection, associated systemic complaints such as myalgias, fever chills. Identify symptoms sepsis including lightheadedness and mental status changes.
• Physical exam: Conduct a physical exam to evaluate and monitor skin infections, determine if lymphangitis or lymphadenopathy is present, determine if mental status changes or hypotension are present.
• Comorbidities: Screen for patients with increased susceptibility such as diabetics

• List and interpret critical clinical and diagnostic tests which are key in the processes of exclusion, differentiation, and diagnosis.
• Differentiate common skin infection from other conditions such as thrombophlebitis, necrotizing fasciitis, dermatitis and other inflammatory conditions
• Categorize skin infections as bacterial, viral, parasitic or fungal
• Assess the severity of the condition to guide the setting most appropriate for management (inpatient vs. Outpatient)
• Identify patients with necrotizing fasciitis

• Communicate an effective initial plan of management for a patient with a bacterial, fungal or viral skin infection
• Use antimicrobial therapy based on category of infection and common pathogens
• List antimicrobials of choice for common skin infections (include side effects)
• Discuss indications for isolation in selected patients
• Select patients in need of multidisciplinary/specialist care

• Name the common pathogens in bacterial skin infections.
• Describe the pathophysiology of acne vulgaris

• Essentials of Family Medicine, Chapter 43.

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

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

Clinical Problem – Social/Domestic Abuse
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) at risk of or experiencing domestic violence and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks (Key Findings)

• History: Through sensitive, focused, data gathering demonstrate competency in routine screening for family violence across the lifespan, including direct and indirect screening questions and instruments. Incorporate a recognition of cultural factors that influence the occurrence and patterns of and responses to family violence in individuals, families, and communities
• Physical: Assess for physical and/or mental health effects persisting into adult life, after childhood experience of abuse or family violence.
• Co-morbidities: Assess for adverse health effects of present and past violence.

• Assess risk of severe injury or death in a patient presenting with family violence-related injuries and illnesses. Provide culturally competent assessment and intervention.
• Recognize the significant physical and mental health effects of both ongoing and prior family violence. Assist the patient with understanding the relationship of violence and abuse to their health problems.
• Recognize the effects of family violence across the lifespan, including the long-term effects on children who are exposed to family violence.
• Recognize intentional injury patterns.

• Provide safety planning for a victim of intimate partner violence.
• Determine appropriate community agencies, social workers, or resource specialists in family violence, as indicated for victims and survivors of family violence.
• Document extent of current and prior injuries through written documentation, use of body maps, and/or photographs.
• Demonstrate, by acknowledging and intervening, the ability to communicate non-judgmentally and compassionately with victims and survivors, and perpetrators of family violence.

• Demonstrate knowledge of Colorado legal statutes that relate to the physicians role and responsibility in family violence

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

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

Clinical Problem – Strains and Sprains
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 strain or sprain and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Through efficient, focused, data gathering determine: occupation, repetitive motions, and precipitating events, mechanism of injury, and maneuvers which reproduce the pain, inflammatory changes, effusion or change in function.
• Physical examination: perform appropriate exam of upper & lower limbs including observation of limb movement, gait, examination and determination of range of motion of joints, assessing muscle mass, and palpation of peripheral arteries.
• Comorbidities: identify possible life/limb threatening associated conditions such as compartment syndrome or is there an associated bony injury.

• Differentiate between different causes of acute and chronic extremity pain.
• List and interpret critical clinical and laboratory findings and decision rules which were key in the processes of exclusion, differentiation, and diagnosis of common upper and lower extremity soft tissue injuries.
• Appropriately select and interpret diagnostic tests to evaluate acute or chronic upper or lower extremity pain.
• Determine if the extremity pain represents an emergency such as compartment syndrome or other vascular compromise.

• Communicate an effective plan of management to a patient and/or their caregivers for an acute strain or sprain of the upper or lower extremity
• Describe indications for RICE, NSAIDs and rehabilitation therapy.
• Outline management for common overuse injuries
• Outline management for exercise-induced injuries which returns patient to physical activity.
• Describe effective strategies for injury prevention
• Select patients in need of multidisciplinary/specialized care.

• Describe the functional anatomy of the ankle, knee and shoulder joints
• Relate the mechanism of injury to the anatomical injury.

• Essentials of Family Medicine, Chapter 20 & 42.

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

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

Clinical Problem – Upper Respiratory Infections
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) with an upper respiratory tract infection and be able to do the following at the level of a Year 3 medical student:

Clinical Tasks

• History: Perform a history to gather information from a patient presenting with possible upper respiratory tract symptoms including smoking history. Elicit historical features that differentiate streptococcal from viral sore throat and bacterial sinusitis from non-bacterial reasons for sinus congestion.
• Physical: Perform an appropriate physical exam on a patient with URI symptoms and include sinus transillumination and nasal exam in patients with sinus symptoms. Recognize significant patterns of cervical lymphadenopathy and pharyngeal exudates in sore throat.
• Co-Morbidities: describe complications of untreated upper respiratory tract infections. Determine if a patient has potential serious conditions such as peritonsillar abscess, epiglottis or other upper airway compromise.

• List and interpret diagnostic tests such as rapid streptococcal tests that are key in the diagnosis of URIs. Understand indications and interpretation on imaging studies in sinusitis.
• Identify serious causes/complications of URIs.
• Use decision tools in the clinical evaluation of sore throat and sinusitis.

• Describe appropriate therapy for URIs, including antibiotics, symptomatic treatments and medications and lifestyle changes.
• Describe preventive strategies for decreasing URIs including smoking cessation hand washing and other measures.
• Use effective communication skills to foster adherence to recommendations and to respond to those patients who express different expectations of treatment for their illness.

• Describe the common pathogens in sore throat, sinusitis and other clinical syndromes of URI.

• Essentials of Family Medicine, Chapter 17
• Section in the clerkship syllabus.

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

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

Clinical Problem – Preventive Health Adults
At the conclusion of this 4-week RCC clerkship we expect students to see a patient (or discuss a case with your preceptor) during a health maintenance visit and be able to do the following at the level of a Year 3 medical student:

Key Findings

• History: elicit an age appropriate history for disease prevention in adults.
• Physical: perform an age appropriate physical examination for disease prevention in adults.
• Comorbidities: Identify risk factors for common diseases in adults.

• Describe the difference between diagnostic and screening tests.
• Identify age appropriate and gender appropriate screening tests for adults and immunization schedule recommendations.
• Recognize indications, evidence supporting screening, recommended tests and frequency of testing.
• Describe cost associated with screening populations and individuals.
• List risk and benefits associated with each screening test.

• Conduct an appropriate plan of management for male and female asymptomatic adults regarding disease prevention including risk assessment, screening immunizations.
• Describe rationale for testing or not testing to patient.

• Describe cellular development of common cancers.
• Describe metabolic development of diabetes.

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

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