The graduate of an ACOI approved residency in Internal Medicine is first and foremost an Osteopathic Physician. Training incorporates the knowledge base and skills necessary to provide primary care from adolescence to geriatrics with the social and academic skills needed to effectively serve this population. In addition, the unique concepts and skills of Osteopathic Medicine are emphasized and blended throughout the training years. This document serves as a guide to the minimum standards and requirements to meet these goals. It defines clearly what trainers will expect from the resident, and what residents in turn can expect from the program. It is not meant to define a specific program structure or academic course, but to establish a universally recognized body of knowledge and skills that will be required of residents in all programs. The focus is on primary (general) internal medicine only, and does not relate to any subspecialty training program. This core data base will serve as the template for resident evaluation and certification by the American Osteopathic Board of Internal Medicine.

This document is the product of extensive cooperative effort of the program directors at the annual Congress, the Council on Education and Evaluation of the ACOI, and review of other established or proposed internal medicine curricula such as the University of Wisconsin Internal Medicine Residency Program and the COGMET educational consortium in Michigan. Expert guidance, analysis and developmental assistance was received from education specialists identified by the Council on Education and Evaluation.

The curriculum is divided into sections. The first group deals with general medical topics. The sections following deal with individual subject areas. Osteopathic principles and manual medicine skills are incorporated into each section where appropriate. Finally, a section regarding biopsychosocial aspects is presented. Although this can be achieved in a rotational setting, it is recommended that the biopsychosocial content be distributed throughout the training program.

Each section is organized into five broad objectives:

1. Aspects of history;
2. Aspects of physical examination;
3. Basic scientific or clinical principles;
4. Diagnostics/Therapeutics;
5. Health Promotion and continuity care.

Since the focus is on development of the general internist, certain skills need not be highly developed, but only recognized by the trainee. Where applicable, two levels of expertise are identified. Level I items are those which the trainee must master as an independent provider. Level II items are those which the trainee must recognize and categorize, and then seek expert assistance in management.

At the completion of the training program, the graduate shall:

1. Accurately identify potential medical problems.
1. describe the medical problems presented;
2. define information in the patient record which aids in said description;
3. elicit and record appropriate history which defines the problem;
4. perform an accurate physical examination to identify and confirm the problems;
5. utilize and interpret laboratory and ancillary testing to define or discover problems.
2. Accurately diagnose problems.
1. describe potential etiologies for each presenting problem;
2. identify signs and symptoms for each problem;
3. prioritize findings with respect to potential etiologies;
4. rank potential disorders by likelihood based on presence or absence of findings.
3. Confirm the diagnosis of the problem.
1. describe the diagnostic resources for each disorder;
2. generate a diagnostic plan to appropriately confirm the disorder;
3. perform diagnostic procedures where appropriate;
4. properly interpret results of testing, recognizing the relative sensitivity and specificity of the tests;
5. understand cost effective diagnostic planning.
4. Competently treat the problems.
1. define the needs and circumstances of the patient;
2. describe the conventional and alternative therapies for each problem;
3. generate treatment plans which are cost effective;
4. monitor response to initiated treatment, including appropriate follow-up testing if needed;
5. determine efficacy of chosen treatment.
5. Communicate effectively.
1. use standard English effectively;
2. use accepted medical terminology appropriately;
3. develop listening skills for patient, family, and ancillary providers;
4. effectively and sensitively respond to patient questions and fears or concerns;
5. record data and plans clearly and completely in progress notes, summary reports, history and physical reports, and procedure reports;
6. develop prompt responsiveness to requests for information or explanation;
7. demonstrate reasonable facility in use of computer network information and record keeping systems.
6. Demonstrate professionalism.
1. be characterized as competent, approachable, empathetic, conscientious, and cooperative;
2. develop sensitive yet definitive leadership capabilities when dealing with house staff, students, or ancillary staff;
3. demonstrate honesty, reliability, and morality;
4. develop a commitment to the medical community and the advancement of medical care in the population.
7. Develop strong work habits.
1. demonstrate ability and commitment to use of continuing medical education tools, such as journals, computer-assisted instruction, and involvement in conference activities both as learner and instructor;
2. recognize personal limitations and obtain appropriate assistance where necessary;
3. perform all record keeping activities promptly and thoroughly;
4. understand requirements of operating in the managed care environment, and how to maximize efficiency;
5. recognize the medico?legal aspects of care, and manage risks appropriately.

1. GENERAL INTERNAL MEDICINE
1. SUBSTANCE ABUSE
1. History.
1. define screening techniques for patients with or at risk for substance abuse;
2. define demographics and related psychosocial factors relating to substance abuse;
3. define diagnostic modalities for each major abused substance;
4. target agents: alcohol, prescription drugs, street drugs including toxins such as toluenes, glues, methanol, etc, and tobacco.
2. Physical exam.
1. perform systematic examination focusing on involved organ systems;
2. recognize classic findings of end organ toxicity for each abused agent.
3. Basic principles.
1. pharmacology of absorption, tolerance, dependence;
2. clinical withdrawal syndromes;
3. cognitive behavior effects;
4. laboratory aberrencies.
4. Diagnostic/therapeutics.
1. treatment of withdrawal syndromes;
2. emergency management of acute toxicity;
3. consider all appropriate alternative treatment strategies;
4. consider compliance issues, patient risk, and cost effectiveness;
5. utilize community resources to assist in rehabilitation;
6. identify appropriate time for referral to specialized care;
7. initiate follow-up planning.
5. Health promotion.
1. understand principles of relapse prevention;
2. psychosocial support.
6. Osteopathic principles.
1. liver pump techniques;
2. venous drainage maneuvers.
2. WOMEN'S MEDICINE
1. History.
1. complete menstrual history (onset, timing, volume, FDLMP, menopause);
2. pregnancy/birth history;
3. substance abuse or medications while pregnant;
4. vaginal protrusion/incontinence;
5. vaginal discharge/itching/masses;
6. postmenopausal bleeding and character;
2. PAP test, breast exam and mammogram history;
1. nipple discharge or breast changes;
2. identify impact of psychosocial factors on sexually transmitted disease, pregnancy, and general health.
3. Physical exam.
1. demonstrate complete breast exam;
2. describe breast masses with respect to location, size, mobility, nipple discharge or retraction, skin changes, lymph nodes;
3. perform adequate pelvic examination to include PAP smear and bimanual examination;
4. identify cystocoele, rectocoele, pediculosis, masses, lichen planus, cervicitis, vaginitis, warts, ulcers (herpetic), imperforate hymen, ovarian and uterine masses or malposition.
4. Basic principles.
1. hirsuitism;
2. menstrual dysfunction;
3. medical disorders of pregnancy;
4. pelvic infection/ sexually transmitted disease;
5. postmenopausal osteoporosis;
6. impotence;
7. fertility control;
8. estrogen/progesterone therapy;
9. PAP smear result interpretation.
5. Diagnostics/therapeutics.
1. wet mount interpretation;
2. PAP smear/colposcopy;
3. hormone evaluation.
6. Health promotion.
1. PAP smear, mammography and breast exam surveillance;
2. behavior modification;
3. STD prophylaxis;
4. psychosocial support for appropriate female ailments.
7. Osteopathic principles.
1. myofascial release to the sacrum;
2. vasculolymphatic drainage techniques;
3. thoracolumbar junction therapy for autonomic tone to pelvis;
4. evaluation of Chapman's reflex points.
3. ADOLESCENT MEDICINE
1. History.
1. obtain adequate information to assess cognitive function, psychomotor skills, personality development, sexuality and psychosocial development;
2. understand the impact of the following on adolescent health: age, sex, race, socioeconomic status, parity/gravity.
2. Physical exam.
1. recognize special findings indicating adolescents at particular risk;
2. pelvic exam on sexually active females;
3. structural exam.
3. Basic principles.
1. biologic maturity;
2. morbidity and mortality;
3. mental health problems.
4. Diagnostics/therapeutics.
1. interpretation of lab and X?ray values which are unique to the adolescent.
5. Health maintenance.
1. immunization schedule;
2. behavior modification and diet;
3. psychosocial support for disruptive behavior.
4. GERIATRIC MEDICINE.
1. History.
1. obtain data to evaluate mental function, physical function, and social dynamic;
2. recognize the presentation of dementia, delerium, auditory and visual impairment, frailty and fatigue, dysautonomia;
3. identify important additional sources of information such as family, significant others, health care providers, friends;
4. recognize the importance of home visits to obtain most helpful information regarding general condition;
5. understand the impact of the following on the elderly: age, race, sex, socioeconomic status, marital status, parity/gravity.
2. Physical exam.
1. Note the unique aspects pertaining to the elderly: normal skin, structural, and organ changes with aging;
2. understand the effects of aging on interpretation of findings;
3. focus on mobility, frailty, general health, nutrition, and sense organ disease.
3. Basic principles.
1. herpes zoster;
2. decubitus ulcer, non?surgical;
3. stasis and ischemic ulcers
4. senile purpura;
5. xerosis and benign skin lesions;
6. cerumen impaction;
7. hiatal hernia/reflux;
8. malnutrition/failure to thrive;
9. diverticular disease;
10. fecal impaction, constipation, incontinence;
11. mesenteric ischemia;
12. anemia;
13. hypertension;
14. dementia/delerium/mental status change;
15. Parkinsonism;
16. cerebral ischemic syndromes;
17. falls/drop attacks;
18. dysautonomia;
19. urinary tract infection/incontinence/colonization/ dysfunction;
20. estrogen deficiency? atrophic vaginitis, osteoporosis;
21. degenerative joint disease/ arthritis;
22. rheumatologic disorders (temporal arteritis, polymyalgia, rheumatoid);
23. atrial fibrillation;
24. myocardial ischemic syndromes;
25. aortic stenosis;
26. congestive heart failure;
27. venous insufficiency;
28. thrombophlebitis/pulmonary embolism;
29. peripheral arterial disease/aortic occlusive disease/aneurysm;
30. aspiration acute and chronic;
31. influenza;
32. hyperosmolar state (DM);
33. thyroid dysfunction;
34. hypo and hyperthermia;
35. polypharmacy/drug toxicity/drug interaction;
36. insomnia/depression/anxiety;
37. elder abuse.
4. Diagnostics/therapeutics.
1. specific tools for each content area above;
2. fall prevention strategies;
3. exercise prescription;
4. hormone replacement therapy.
5. Health promotion.
1. cancer screening;
2. immunization;
3. behavior modification.
6. Osteopathic principles.
1. primary use of muscle energy techniques, fascial release and counterstrain rather than high velocity thrust;
2. goal is to maintain mobility and functional status rather than to focus on reversal of dysfunction;
3. posture and strengthening exercises to maintain mobility and reduce energy expenditure.
2. ALLERGY/IMMUNOLOGY
1. History.
1. Describe the symptoms of urticaria, acute and chronic;
2. Obtain accurate and complete environmental exposure history;
3. Thorough family history of atopy, urticaria, and immune deficiency;
4. Recognize occurrence patterns of symptoms consistent with allergic response;
5. Obtain history of blood transfusions and transplants;
6. Obtain history of prior immunotherapy and immunosuppressive therapy;
7. Obtain complete immunization history;
8. Obtain a history to categorize the severity of asthma.
2. Physical examination.
1. Recognize the characteristic skin lesions of immune disorders;
2. Define the normal distribution of lymph nodes and the characteristics of abnormal nodes;
3. Recognize the phase characteristics of Raynaud's phenomenon;
4. Describe signs of uveitis and scleritis;
5. Detect fever patterns and diurnal variations;
6. Detect joint and synovial inflammation and dysfunction;
7. Recognize the pulmonary auscultory findings with interstitial allergic disorders;
8. Recognize the signs of asthma;
9. Recognize atopic disease of the skin to include urticaria, angioedema, atopic dermatitis and drug rash.
3. Basic principles.
1. Anaphylaxis;
2. Allergic bronchopulmonary aspergillosis;
3. Asthma;
4. Atopic eczema;
5. Contact dermatitis;
6. Drug reaction-allergic and non-allergic;
7. Erythema nodosum;
8. Stevens-Johnson syndrome;
9. Allergic rhinitis
10. Immune complex disorders:
1. serum sickness;
2. mixed cryoglobulinemia;
11. Anticardiolipin syndrome;
12. Serologic markers for HIV infection, and the appropriate stepwise screen and confirmatory testing;
13. Serologic testing for connective tissue disorders (refer to Rheumatology Section);
14. Urticaria, angioedema, and hereditary angioedema;
15. Food and gastrointestinal allergy;
16. Chronic fatigue;
17. Hyper-immunoglobulin E syndrome;
18. Hypereosinophilia syndrome;
19. Vasculitis;
20. Hymenoptera sensitivity.
21. Sinusitis;
22. Otitis media;
23. Nasal polyps;
24. Immunoglobulin deficiencies and other primary deficiencies;
25. Hypersensitivity pneumonitis.
4. Diagnostics/therapeutics.
1. IgE testing;
2. T and B cell assay and interpretation;
3. Testing for neutrophil and macrophage function;
4. Tissue typing principles (esp. Blood);
5. RAST testing;
6. Schirmer test;
7. Synovial biopsy;
8. Skin testing for immediate hypersensitivity;
9. Serum protein electrophoresis;
10. Skin testing for delayed hypersensitivity (Tine and PPD, anergy panel);
11. Coombs testing-direct and indirect;
12. Cryoglobulin;
13. Complement component measurement and interpretation;
14. Drug challenge;
15. Immunotherapy principles-desensitization;
16. Plasmapheresis indications;
17. Appropriate use of steroids;
18. Appropriate use of antihistamines;
19. Appropriate use of nonsteroidal antiinflammatories
20. Appropriate use of immunoglobulin;
21. Immunotherapy.
5. Health maintenance.
1. Immunization principles in adults;
2. Prophylaxis in splenectomy patients;
3. Emergency bee sting kit education;
4. Family screening for heritable immune deficiency syndromes
5. Travel vaccine.
3. DERMATOLOGY
1. History.
1. describe lesions by color, size, distribution;
2. sensory findings;
3. familial occurrence;
4. exposure history;
5. question regarding the following: acne, discoloration, changes in moles, warts, cysts, corns/calluses, rashes, ulcers, blisters, pain/itching, nodules, masses, sore toenails, hair changes, toxic topical exposures.
2. Physical exam.
1. recognize macule, papule, bulla, plaque, nodule, wheal, vesicle, pustule, cyst, atrophy, ulcer, scaling, crusts, purpura, petechiae, stria, tumor;
2. detect the difference between primary and secondary bulla;
3. detect normal and abnormal hair patterns;
4. demonstrate proper lighting technique and full skin examination;
5. recognize common nail disorders.
3. Basic principles.
1. drug eruption;
2. skin cancer;
3. immune mediated skin disorders;
4. skin infections;
5. photosensitivity syndromes;
6. AIDS lesions (Kaposi's).
4. Diagnostics/therapeutics.
1. utilize laboratory for above disorders where appropriate;
2. KOH slide for fungi;
3. appropriate therapy for each disorder above.
5. Health maintenance
1. education on sunscreen use;
2. surveillance of suspicious lesions.
4. CARDIOVASCULAR MEDICINE
1. History.
1. dyspnea (exertional, resting, orthopnea, platypnea, nocturnal);
2. chest pain;
3. edema;
4. exercise intolerance and functional class;
5. heart murmur or rheumatic fever;
6. family history of cardiac illness;
7. hypertension;
8. congestive heart failure;
9. ischemic cardiac disease;
10. arrhythmia with or without syncope;
11. previous cardiac testing;
12. claudication;
13. deep venous thrombosis/embolus;
14. chest trauma/surgery;
15. stroke/TIA.
2. Physical exam.
1. proper five phase BP measurement;
2. detect conditions which affect accurate determination of BP: auscultory gap, atherosclerosis, limb position, cuff size, arrhythmia;
3. obtain BP in all extremities and in two positions;
4. demonstrate technique and understanding of the principles for detecting pulsus paradoxicus, pulsus bisferiens, pulsus tardis et parvus, pulsus alternans;
5. detect signs of right and left ventricular failure;
6. describe heart murmurs as to location, timing, quality, radiation, intensity, and determine the valvular lesion by the type;
7. detect left and right ventricular heaves by palpation, along with placement of PMI and presence of thrills;
8. detect normal and variant S1, S2, S3 and S4;
9. detect opening snap, systolic click, pericardial rub, and normal or paradoxic splitting of S2;
10. detect differential swelling of extremities and edema.
3. Basic principles.
1. LEVEL I
1. congestive heart failure;
2. cardiac arrhythmias;
1. AV block;
2. PSVT;
3. atrial tachycardia/flutter/fibrillation;
4. junctional rhythm/tachycardia;
5. ventricular rhythm/tachycardia/fibrillation;
3. bundle branch block;
4. angina/infarction;
5. pericarditis/tamponade;
6. valvular heart disease;
7. Dressler syndrome;
8. cardiomyopathies? restrictive, dilated, hypertrophic;
9. myocarditis/endocarditis;
10. cor pulmonale;
11. pulmonary embolism/hypertension;
12. orthostatic hypotension/syncope;
13. hypertension/hypertensive heart disease;
14. Raynaud's phenomenon;
15. varicose veins/venous thrombosis/postphlebitic syndrome;
16. vasculitis;
17. atherosclerosis/risk factors.
2. LEVEL II.
1. atrial myxoma;
2. constrictive pericarditis;
3. aortic aneurysm;
4. anomalous AV conduction (WPW); (5) acute arterial occlusion;
5. A?V fistula;
6. recurrent ventricular tachycardia;
7. aortitis/Takayasu's;
8. thromboangitis obliterans;
9. coarctation;
10. subclavian steal syndrome;
11. Leriche syndrome;
12. hypertrophic obstructive cardiomyopathy;
13. cardiogenic shock;
14. ventricular aneurysm;
15. lymphedema.
4. Diagnostics/therapeutics.
1. echocardiography?interpretation;
2. chest X?ray? interpretation;
3. exercise stress test? performance and interpretation;
4. ECG? performance and interpretation;
5. Swan Ganz catheterization? assist or perform;
6. D.C. cardioversion? perform;
7. temporary transvenous pacemaker insertion? assist or perform;
8. pericardiocentesis?assist;
9. stuctural evaluation?perform and interpret.
5. Health maintenance.
1. risk factor modification;
2. low fat diet;
3. cholesterol/BP screening;
4. smoking sessation;
5. stress reduction/exercise prescription.
6. Osteopathic principles.
1. reflex inhibition to thoracic trigger points T1?T5, predominantly for sympathetic discharge which may affect tachydysrhythmias or spasm;
2. occipito?atlantal therapy for parasympathetic outflow with potential effect in bradyarrhythmias;
3. limb fascial release for vascular insufficiency.
5. ENDOCRINOLOGY
1. History.
1. genital maturation/menarche;
2. growth and development;
3. thyroid dysfunction;
4. steroid use;
5. endocrine surgery/trauma;
6. weight variation;
7. edema;
8. radiation exposure;
9. family history of DM, goiter, growth defects, obesity.
2. Physical exam.
1. height/weight/ proportion;
2. skin fold thickness.
3. hyperpigmentation, stria, acne;
4. hirsuitism;
5. exophthalmous;
6. thyroid nodule, size texture;
7. voice changes, breath odor;
8. inappropriate breast development;
9. genital structure and health.
3. Basic principles.
1. LEVEL I:
1. adrenal insufficiency;
2. hyperadrenalism? endogenous/exogenous;
3. hyperaldosteronism;
4. diabetes mellitus;
5. diabetic ketoacidosis;
6. hyperosmolar coma;
7. hypoglycemia/insulinoma;
8. thyroid imbalance;
9. goiter? hypo and hyperfunctioning;
10. thyroid nodules/thyroiditis;
11. parathyroid imbalance;
12. SIADH;
13. diabetes insipidus;
14. osteoporosis;
15. calcium imbalance/Paget's disease of bone;
16. protein?calorie malnutrition;
17. vitamin deficiencies;
18. obesity/anorexia/bulemia;
19. pheochromocytoma;
20. hyerlipidemia;
21. polycystic ovarian disease/amenorrhea;
22. impotence.
2. LEVEL II:
1. Reidel's struma;
2. thyroid carcinoma;
3. acute suppurative thyroiditis;
4. carcinoid;
5. dwarfism;
6. hypogonadism;
7. porphyrias;
8. Wilson disease;
9. panhypopituitarism.
4. Diagnostics/therapeutics.
1. suppression/stimulation testing:
1. fasting stress (insulinoma);
2. TRH;
3. ACTH;
4. dexamethasone suppression;
5. water deprivation.
2. special lab tests:
1. glycosylated hemoglobin;
2. glucose tolerance test;
3. serum hormone levels;
4. insulin and c?peptide;
5. serum catecholamines;
6. plasma renin activity/ aldosterone;
7. urine VMA/metanephrines;
8. urine HCG.
3. imaging procedures:
1. sella turcica x?ray/MRI;
2. thyroid radionuclide study;
3. ultrasound thyroid;
4. structural exam.
5. Health maintenance.
1. dietary support for diabetics;
2. hypertension control.
6. GASTROENTEROLOGY
1. History.
1. family history of inflammatory bowel disease, peptic ulcer, bowel cancer or polyps, celiac disease or lactase deficiency;
2. sexual history;
3. mouth and tongue symptoms including bleeding, pain, soreness, ulcer, swelling, lumps;
4. dysphagia, eructation, dyspepsia, odynophagia;
5. vomiting/nausea/anorexia;
6. abdominal pain/bloating/swelling;
7. blood in stool, constipation, diarrhea, stool changes;
8. anal discharge;
9. anal pruritis/worms;
10. pain or mass in rectum or perirectal area;
11. jaundice;
12. weight loss or gain;
13. food intolerance.
2. Physical exam.
1. abdominal shifting dullness/ballottement;
2. sequential exam of the acute abdomen: auscultation first, light palpation least tender area next, then most tender area; rebound, guarding, spasm;
3. know importance of serial abdominal exam;
4. rectal/pelvic exam;
5. light/deep palpation for masses, hernia;
6. auscultation for bruits;
7. palpatory examination of the spleen, liver, abdominal aorta, hernias of the abdominal wall, masses;
8. detection of voluntary vs involuntary guarding, rigidity;
9. performance and understanding of the iliopsoas and obturator tests.
3. Basic principles.
1. reflux esophagitis/varices;
2. hiatal hernia;
3. acid peptic disease;
4. upper and lower GI bleeding;
5. postoperative ileus;
6. diarrhea?acute, chronic, physiologic;
7. diverticular disease;
8. inflammatory bowel disease;
9. irritable bowel syndrome;
10. esophageal motility disorder;
11. diabetic gastropathy and enteropathy;
12. gut infections? bacterial, parasitic, viral;
13. pseudomembranous colitis;
14. hemorrhoids/anal fissures/pruritis ani;
15. hyperbilirubinemias? conjugated and unconjugated? familial;
16. drug induced cholestasis;
17. cirrhosis? alcoholic, cardiac;
18. hepatitis A?E, toxic, chronic persistent and chronic active;
19. cholangitis/cholecystitis/cholelithiasis;
20. pancreatitis/pseudocyst/cancer;
21. malnutrition/malabsorption;
22. volvulus/Meckel's diverticulum;
23. ischemic bowel;
24. gay bowel syndrome;
25. hernias.
4. Diagnostics/therapeutics.
1. flexible sigmiodoscopy;
2. paracentesis;
3. insertion of central venous catheter for parenteral nutrition;
4. insertion of nasogastric tube;
5. liver biopsy? assist;
6. structural examination and therapy;
7. interpretation of appropriate laboratory tests to confirm findings in areas listed above;
8. understand indications for appropriate surgical procedures to include:
1. cholecystectomy;
2. peptic ulcer surgery;
3. hiatal hernia repair;
4. abdominal wall herniorrhaphy;
5. exploratory laparotomy;
6. bowel resection;
7. enterostomy/gastrostomy;
8. peritoneal shunts;
9. endoscopic procedures? assist:
1. esophageal dilation;
2. sclerotherapy for esophageal variceal bleeding;
3. palliative therapy for esophageal, gastric and colonic tumors;
4. sphincterotomy of the Ampulla of Vater;
5. stenting of bile duct;
6. polypectomy.
5. Health maintenance.
1. recommended bowel screening protocol;
2. colonic surveillance for polyps;
3. dietary management of colonic disease and malabsorption;
4. psychosocial support for gut dysfunction.
6. Osteopathic principles.
1. liver pump drainage techniques;
2. direct myofascial relase to rectus abdominus and psoas spasm;
3. focus paraspinal areas for sympathetic reflexes:
1. T5?T9 for gastric and espophageal motility;
2. T12?L2 for bowel function and IBS;
3. occipito?atlantal therapy for parasympathetic outflow with nausea and gastroparesis.
7. HEMATOLOGY
1. History.
1. fatigue, early exhaustion, anorexia, weight loss;
2. abnormal bleeding;
3. skin lesions, lumps, swellings, masses;
4. family history of tumors;
5. medications, drug use, alcohol, toxin exposure, smoking;
6. fever of unknown origin;
7. trauma and prior surgery.
2. Physical exam.
1. observe changes in fundi, sclera, conjunctiva, mouth, nose;
2. lymph nodes;
3. nails and nail beds;
4. tongue;
5. bones and joints;
6. liver and spleen;
7. structural examination.
3. Basic concepts.
1. iron deficiency anemia and sideroblastic anemia;
2. megaloblastic anemia;
3. bone marrow failure;
4. aplastic anemia and myelophthisis;
5. anemia of chronic disease;
6. hemolytic anemia;
7. hemoglobinopathies;
8. platelet disorders;
9. clotting/bleeding disorders;
10. blood typing and transfusion medicine;
11. polycythemia vera;
12. myeloproliferative disorders;
13. diseases of the reticuloendothelial system;
14. acute and chronic leukemia;
15. Hodgkin's disease/lymphoma;
16. myeloma/gammopathy;
17. AIDS and its cancers.
4. Diagnostics/therapeutics.
1. bone marrow aspiration and core biopsy;
2. peripheral blood smear interpretation;
3. template bleeding time;
4. lumbar puncture for intrathecal therapy? assist;
5. thoracentesis, paracentesis, skin biopsy for diagnostic purposes;
6. osteopathic structural examination.
5. Health promotion.
1. ACS cancer screening protocols for GI, GYN, prostate, breast cancer;
2. hospice;
3. chronic pain management;
4. advanced directives.
8. INFECTIOUS DISEASES
1. History.
1. fever curve;
2. recent patient contacts;
3. travel and family history;
4. complete sexual history;
5. work/environmental exposures;
6. surgical/dental procedures or trauma;
7. detection of immunocompromising disorders (diabetes, carcinoma, steriod use, alcohol, etc.);
8. drug abuse/smoking;
9. discharges, odors, sores, swellings, rashes.
2. Physical exam.
1. skin lesions typical of specific organisms;
2. typical fever patterns of specific organisms;
3. identify and differentiate findings for the following:
1. skin abscess, cellulitis, lymphangitis, phlebitis;
2. conjunctivitis, sty, uveitis, blepharitis, periorbital cellulitis;
3. pharyngitis and pharyngeal abscess;
4. otitis externa, media, and serous otitis;
5. bronchitis, pneumonia, abscess, empyema;
6. peritonitis, cholangitis, pelvic infection, abscess;
7. septic joint, bursitis, osteomyelitis;
8. urethritis, cystitis, nephritis, abscess;
9. sialoadenitis, thyroiditis;
10. paronychia/felon;
11. meningitis, brain and epidural abscess;
12. botulism, Guillian?Barre, transverse myelitis;
13. infectious mononucleosis;
14. food poisoning;
15. systemic fungemias;
4. osteopathic structural examination.
3. Basic concepts.
1. septic shock;
2. iatrogenic infections;
3. infected prosthetic devices or central lines;
4. endocarditis;
5. toxic shock;
6. human and animal bites;
7. infectious pericarditis/mediastinitis;
8. travel related immunizations;
9. AIDS;
10. urinary tract infections;
11. gram negative sepsis;
12. tuberculosis;
13. sexually transmitted diseases;
14. antibiotic associated colitis;
15. fever of unknown origin.
4. Diagnostic/therapeutics.
1. X?ray interpretation: chest, bone, soft tissue;
2. nuclear scan interpretation: gallium, indium technetium;
3. cytology;
4. serology;
5. antibiotic utilization: cost effectiveness, indications, dosing monitoring;
6. specimen collection;
7. gram staining.
5. Health promotion.
1. screening/immunizations.
6. Osteopathic principles.
1. lymphatic drainage techniques; b. myofascial release in peripheral infections.
9. NEPHROLOGY
1. History.
1. urine frequency/volume/color/odor;
2. dysuria,change in stream, hesitancy, urgency, dribbling;
3. urinary incontinence;
4. hematuria;
5. flank pain, groin pain;
6. stones, abscesses;
7. family history of renal disease;
8. edema/hypertension;
9. sexual activity.
2. Physical exam.
1. uremic "frost";
2. renal masses;
3. phimosis;
4. urinalysis;
5. Lloyd's sign;
6. edema;
7. urethral discharge;
8. prostate evaluation;
9. genital skin lesions;
10. scrotal contents abnormalities.
3. Basic concepts.
1. LEVEL I:
1. prostatitis/epididymitis/orchitis;
2. testicular torsion/varicocoele/tumor/hydrocoele;
3. erectile dysfunction;
4. prostatic hypertrophy/masses;
5. balanitis/genital ulcers;
6. condyloma/genital granulomas;
7. basic infertility;
8. hypertension: essential, secondary, accelerated, malignant, crisis;
9. primary glomerulopathies: histology, natural history;
10. nephrotic and nephritic syndrome;
11. diabetic kidney;
12. immune complex nephropathy;
13. hepatorenal syndrome;
14. myeloma/amyloid kidney;
15. vasculitis;
16. AIDS;
17. interstitial nephritis;
18. nephrolithiasis;
19. obstructive uropathy;
20. hereditary tubular disorders;
21. acute and chronic renal failure;
22. renal osteodystrophy;
23. vitamin D metabolism;
24. renin?aldosterone axis;
25. renal tubular acidosis;
26. electrolyte management;
27. acid/base;
28. hemodialysis/peritoneal dialysis/transplantation.
2. LEVEL II
1. genital neoplasms;
2. prostatic abscess;
3. priapism;
4. urethral stenosis;
5. phimosis;
6. prostatic malignancy;
7. Peyronie's disease.
3. Diagnostics/therapeutics.
1. renal function evaluation: glomerular filtration rate, urine/serum osmolarity, fractional excretion of sodium, renal failure index, creatinine clearance;
2. renal imaging: IVP, ultrasonography, renal scan;
3. renal biopsy? assist;
4. urinalysis with microscopic;
5. arterial blood gas analysis;
6. temporary vascular access for hemodialysis? assist;
7. insertion of peritoneal dialysis catheter (temporary);
8. peritoneal dialysis;
9. osteopathic structural exam.
4. Health promotion.
1. outpatient dialysis prescription;
2. support group advising for dialysis patients;
3. donor acquisition for transplant program;
4. dietary management for chronic renal failure.
5. Osteopathic principles.
1. lower thoracic and upper lumbar segmental reflexes in ureteral spasm and adjunct pain management;
2. upper lumbar segmental reflexes for bladder dysfunction and spasm.
10. NEUROLOGY
1. History.
1. nature of dysfunction and mode of onset;
2. toxins or other environmental exposures;
3. trauma/infections;
4. activities of daily living;
5. family history.
2. Physical exam.
1. complete cranial nerve evaluation;
2. muscular tone, strength, fasciculations, wasting;
3. reflex testing, clonus, Babinski, Chaddock, Bing;
4. cerebellar testing;
5. gait observation;
6. sensory testing to include pain, light touch, temperature, vibratory, position, neglect;
7. mental status exam.
3. Basic concepts.
1. cephalgia: tension, vascular, cluster;
2. vertigo;
3. CNS infections, hemorrhage, trauma, edema;
4. concussion, epidural and subarachnoid hematoma;
5. seizures: status epilepticus, classification, evaluation, indications for treatment;
6. coma;
7. cerebrovascular disease: CVA, TIA, RIND, stroke in evolution, intracranial; hemorrhage and aneurysms;
8. fluent and non?fluent aphasia;
9. dementia: multi?infarct, metabolic, Alzheimer's, degenerative, toxic;
10. meningitis, encephalitis;
11. movement disorders: Parkinsonism, tardive dyskinesia, essential and secondary tremor;
12. multiple sclerosis;
13. muscular dystrophies;
14. polyneuropathy, mononeuritis, myasthenia gravis, Guillian Barre;
15. neuro?ophthamology: normal fundus, papilledema, Marcus? Gunn pupil;
16. syncope;
17. pituitary adenoma;
18. spinal cord compression, corda equina syndrome;
19. primary and secondary brain tumors;
20. Eaton?Lambert syndrome.
4. Diagnostics/therapeutics.
1. lumbar puncture;
2. EEG? assist;
3. cerebral angiogrphy? interpretation;
4. CT/MRI scanning? interpretation;
5. myelography?assist;
6. evoked potentials? interpret;
7. EMG assist;
8. doppler ultrasound of carotids? interpret;
9. osteopathic structural exam.
5. Health promotion.
1. psychosocial support;
2. genetic counselling.
6. Osteopathic principles.
1. focus on secondary structural changes and spasm with myofascial release, counterstrain, and mobility therapy;
2. cervical myofascial release for tension cephalgia;
3. short leg syndrome therapy.
11. ONCOLOGY
1. History.
1. carcinogens in environment/workplace;
2. family history and genetic predisposition;
3. exposure to radiation, toxins, drugs, hormones;
4. tobacco use;
5. sun exposure;
6. fatigue, weakness, weight loss, anorexia;
7. bleeding;
8. masses, lumps, changes in skin lesions;
9. bowel habit change, bloating;
10. fever, sweats;
11. dysphagia, mouth sores;
12. jaundice, abdominal pain;
13. dyspnea, edema;
14. mental status change, delerium, neurologic abnormalities, personality change;
15. chronic cough.
2. Physical exam.
1. masses;
2. pallor;
3. edema;
4. skin changes;
5. complete lymph node examination;
6. rectal exam and occult blood testing;
3. Basic concepts.
1. pathophysiology of neoplasia: growth patterns, doubling time, etiologies;
2. cancer chemotherapy principles: first and second order cell kill, marrow salvage;
3. breast cancer;
4. ovarian cancer;
5. genital cancer/testicular cancer;
6. prostatic hypertrophy and malignancy;
7. skin cancers;
8. paraneoplastic syndrome;
9. oncologic emergencies including hemorrhage, sepsis, hypercalcemia, seizures, coma, cauda equina syndrome;
10. hemochromatosis;
11. liver/gall bladder/ductal carcinoma;
12. GI tract cancer and pancreas;
13. lung cancer;
14. urinary tract cancer;
15. radiation injury;
16. endocrine neoplasms: Zollinger?Ellison, gastrinoma, carcinoid thyroid/parathyroid cancer;
17. CNS tumors.
4. Diagnostics/therapeutics.
1. bone marrow aspiration/biopsy;
2. thoracentesis/paracentesis;
3. osteopathic structural exam.
5. Health promotion.
1. hospice care;
2. pain management;
3. psychosocial support;
4. rehabilitation;
5. nutritional support.
6. Osteopathic principles.
1. liver/spleen pump techniques;
2. lymphatic drainage techniques.
12. PULMONARY
1. History.
1. dyspnea: exertional, positional, rest;
2. cough: productive, dry, character, frequency, pattern changes, color, quantity of sputum;
3. wheezing, stridor;
4. environmental exposures;
5. past history of lung or functional disorder;
6. previous pulmonary testing;
7. snoring, hypersomnolence;
8. hemoptysis;
9. voice changes;
10. chest pain.
2. Physical exam.
1. extrapulmonary findings in lung disease:
1. cyanosis;
2. clubbing;
3. chest configuration;
2. respiration patterns:
1. Cheyne?Stokes;
2. Kussmaul;
3. accessory muscle use/abdominal paradox;
4. thoracic structural abnormalities;
5. detection and character of crackles, wheezes, ronchi, post?tussive crackles, tubular breath sounds;
6. pleural friction rub;
7. differentiation of effusion from consolidation with percussion in multiple positions, egophony, e?to?a;
8. subcutaneous emphysema;
9. diaphragmatic immobility.
3. Basic concepts.
1. LEVEL I
1. aspiration pneumonitis;
2. lung abscess/pneumonia/bronchitis/colonization;
3. hypersensitivity pneumonitis;
4. bronchiolitis/tracheitis;
5. allergic bronchopulmonary aspergillosis;
6. infiltrate with eosinophilia;
7. emphysema/chronic bronchitis/asthma;
8. pulmonary embolism/infarction;
9. bronchopulmonary hemorrhage;
10. sleep apnea;
11. pulmonary contusion/rib fracture/burns/drowning;
12. pneumothorax;
13. ARDS;
14. atelectasis; basic physiology of respiration;
15. pulmonary function testing;
16. rheumatoid lung and other connective tissue disorders;
17. cor pulmonale.
2. LEVEL II
1. mediastinitis/tumors;
2. empyema;
3. alveolar proteinosis/BOOP;
4. desquamative intersititial pneumonitis;
5. eosinophilic granulomatosis;
6. sarcoidosis;
7. Churg?Strauss syndrome/vasculitis;
8. Wegener's granulomatosis;
9. Goodpasture's syndrome;
10. fungal/TB granulomatosis;
11. foreign body;
12. hemosiderosis;
13. cystic fibrosis;
14. flail chest;
15. primary pulmonary hypertension.
4. Diagnostics/therapeutics.
1. LEVEL I
1. ventilator management/physiology/weaning parameters/modes/adjustments/trouble shooting;
2. arterial blood gas performance and interpretation;
3. pleural biopsy?assist;
4. thoracentesis;
5. simple spirometry;
6. pleural fluid analysis;
7. sputum induction;
8. direct flourescent Legionella antibody in sputum/urine;
9. gram stain;
10. basic hypersensitivity testing;
11. endotracheal intubation;
12. chest tube drainage;
13. lung scan/gallium scan;
14. pre?operative evaluation;
15. osteopathic structural evaluation.
2. LEVEL II
1. bronchoscopy/biopsy/lavage;
2. fluoroscopy;
3. MRI/CT of chest;
4. lung biopsy or aspiration;
5. pulmonary angiography;
6. cardiopulmonary stress testing;
7. complete pulmonary function testing with methycholine challenge;
8. tracheotomy;
9. mediastinoscopy;
10. lung transplantation protocol.
5. Health maintenance.
1. smoking cessation;
2. immunizations;
3. rehabilitation;
4. support groups;
5. screening exams.
6. Osteopathic principles.
1. thoracic pump;
2. rib raising techniques;
3. diaphragmatic release techniques;
4. appropriate chest physiotherapy on ventilated patients.
13. RHEUMATOLOGY
1. History.
1. joint pain, stiffness, motion dysfunction, swelling, muscle pain;
2. neck, low back and thoracic spine pain and motion dysfunction;
3. weakness, joint instability or locking;
4. sensory dysfunction;
5. functional limitations? ADL's;
6. occupational and athletic history;
7. prior treatment and responses;
8. family history;
9. joint symmetry/asymmetry-distribution.
2. Physical examination.
1. erythemas, Heberden's nodes, Bouchard nodes, ulnar deviation, Dupuytren's contracture, tophi, thenar atrophy, foot drop, varus/valgus deformity;
2. osteopathic evaluation including bulge, ballottement, crepitus, stability, range of motion, strength, spinal loading, spasm, stretch testing;
3. posture, gait, movement;
4. chest expansion for spondylitis;
5. leg length;
6. sacroiliac motion testing;
7. anal sphincter tone;
8. sensory and reflex examination
9. warmth, effusion, deformity, range of motion all joints, nodules;
10. proximal and other muscle strength/weakness;
11. skin changes, including raynaud's;
12. range of motion of cervical, thoracic, lumbar spine.
3. Basic concepts.
1. laboratory use:
1. rheumatoid factor;
2. ANA;
3. cryoglobulins;
4. sedimentation rate;
5. immunogenetics--anti-DNA, anti-ENA, ANCA
6. CBC, routine urinalysis, biochemistry profile;
2. x-ray interpretation
1. non?articular rheumatism:
2. fibromyalgia;
3. bursitis/tendonitis;
4. polymyalgia rheumatica;
5. carpal tunnel syndrom/other entrapment syndromes;
6. reflex sympathetic dystrophy.
7. mono?articular disease:
8. infectious arthritis;
9. crystal deposition disease;
10. internal derangement;
11. bursitis/tendinitis.
3. malignancy associated disease:
1. hypertrophic pulmonary arthropathy;
2. palmar/plantar fasciitis;
3. seronegative rhematoid arthritis;
4. dermatomyositis;
5. amyloidosis;
6. osteoarthritis;
7. gout.
4. polyarticular disease:
1. rheumatoid arthritis;
2. juvenile chronic polyarthritis;
3. seronegative spondyloarthropathies including enteropathic arthropathies, reactive arthritis, psoriatic arthritis;
4. systemic lupus erythematosis;
5. vasculitis:
1. hypersensitivity angiitis;
2. giant cell arteritis;
3. necrotizing angiitis;
4. Sjogren's;
6. systemic sclerosis;
7. viral arthritis, parvoviris, Hepatitis B, Aids.
5. metabolic bone disease - osteoporosis, paget's, hyperparathyroidism.
6. immunology:
1. complement;
2. mediators/lymphokines;
3. cellular immunology.
7. Diagnostics/therapeutics.
1. joint aspiration;
2. joint injection;
3. polarizing microscopy;
4. osteopathic evaluation and treatment.
8. Health maintenance.
1. screening;
2. immunizations;
3. physical therapy.
9. Osteopathic principles.
1. range of motion therapy;
2. myofascial release, especially in fibromyalgia;
3. counterstrain techniques for fibromyalgia.
14. BEHAVIORAL MEDICINE
1. History.
1. complete medical history with recognition of the role medical illness may play in psychiatric or behaviorial disorders;
2. family history, to include social or psychiatric dysfunction in current family unit or first degree relatives;
3. sexual history;
4. risk factor identification;
5. social stimuli which may impact behavior or psychologic status;
6. markers to identify illness as early or advanced;
7. specific historical features of each illness listed in basic principles section;
2. Physical examination
1. body habitus
2. affect;
3. complete physical examination with emphasis on aspects demonstrating underlying behavioral or psychologic dysfunction;
4. neurologic examination focus;
5. mental status evaluation.
3. Basic principles.
1. LEVEL I
1. primary degenerative dementia, senile onset;
2. multi?infarct dementia;
3. tobacco dependence;
4. dysthymic disorder;
5. panic disorder;
6. somatization disorder;
7. hypochondriasis;
8. simple psychosexual dysfunction;
9. death and dying;
10. anorexia nervosa/bulemia;
11. substance?induced organic mental disorders;
12. major depression;
13. cyclothymic disorder;
14. phobic disorders;
15. generalized anxiety disorder;
16. spouse or other family member abuse.
2. LEVEL II
1. mild to profound mental retardation;
2. schizophrenic disorders;
3. paranoid disorders;
4. bipolar disorder;
5. complex psychosexual disorder;
6. marital dysfunction;
7. parent?child dysfunction;
8. psychoimmunology.
4. Diagnostics/Therapeutics.
1. basic neuropsychologic testing;
2. Minnesota Multiphasic Personality Inventory;
3. Mini?mental status examination;
4. Beck depression inventory;
5. patient self?monitoring techniques;
6. basic counseling approaches to appropriate illnesses;
7. recognition of appropriate point of referral;
8. identification of the role of therapists including:
1. psychiatrist;
2. psychologist;
3. social worker;
4. counselors;
5. clergy;
6. substance abuse team.
9. use of psychotropic medication for illnesses specified:
1. analgesics;
2. neuroleptics;
3. anxiolytics;
4. antidepressants;
5. stimulants.
10. behavior modification techniques.
5. Health maintenance.
1. recognition of social factors affecting condition;
2. medical compliance;
3. behavior modification compliance;
4. establishment of appropriate psychosocial support systems.
15. PALLIATIVE MEDICINE
1. History.
1. obtain a complete history of pain including, site, character, and intensity;
2. obtain history of the primary diseases(s), including treatment history;
3. obtain a psychosocial history from patient and family.
2. Physical Exam.
1. assess hydration;
2. assess mental status;
3. perform a thorough skin exam, including perineal areas;
4. perform a through oral exam;
5. examination pertinent to primary disease(s).
3. Basic principles.
1. death and dying;
2. grief and loss;
3. family dimension of death and dying, including psychosocial and spiritual impact;
4. integrated health care; home care, hospice, skilled nursing facility, acute care;
5. pathophysiology of pain;
6. classification of pain; somatic, visceral, neuropathic;
7. total pain;
8. anorexia in cancer and HIV;
9. terminal confusion and agitation.
4. Diagnostics/therapeutics.
1. use of diagnostic aides with the goal of improving symptoms;
2. disease specific treatments with the goal of improving symptoms;
3. use of the World Health Organization ladder;
4. use of narcotic pain medications;
5. use of alternative routes of administration of symptomatic medications;
6. treatment of neuropathic pain;
7. treatment and prevention of constipation and obstipation;
8. treatment and prevention of bowel obstruction in the terminally ill;
9. treatment of dyspnea and pulmonary secretions in the terminally ill.
5. Health maintenance.
1. bereavement.
6. Osteopathic principles.
1. soft tissue;
2. stain counterstain;
3. muscle energy.