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Rationale

The chronic obstructive pulmonary diseases (chronic bronchitis/emphysema) are important causes of morbidity and mortality and are a major cause of total disability, second only to coronary artery disease. Cigarette smoking plays a major role in the progression of the disease, with survival rates lower among patients who continue to smoke cigarettes. The severity and debilitation of these particular disorders make them an important training problem for all third year medical students.

Prerequisite

Prior knowledge, skills and attitudes during the pre-clinical (basic science) years should include:

  1. normal structure and function of the heart and lungs and how these are altered in respiratory system diseases
  2. pathogenesis and pathophysiology of pulmonary diseases
  3. harmacology of drugs used for pulmonary diseases
  4. epidemiology and risk factors of lung disease
  5. ability to take a medical history and perform a physical exam
  6. ability to communicate with patients of diverse backgrounds
  7. ability to perform a respiratory risk assessment

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. disease entities and pathophysiologic processes of common, serious, or prototypical respiratory diseases that can result in COPD
    2. other disease entities that may cause symptoms or signs similar to those caused by COPD
    3. allergic and non-allergic factors that may precipitate bronchospasm and asthma
    4. the risks for developing COPD in various patients and correlate risk factors associated with each respiratory tract diseases with occupational and environmental hazards
    5. basic principles of O2, antibiotic, bronchodilator and corticosteroid therapy
    6. the scientific evidence supporting use of influenza vaccine/pneumovax in COPD patients
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including:
      1. existence, duration, and severity of the following symptoms:
      2. shortness of breath
      3. sputum production
      4. cough
      5. wheezing
      6. hemoptysis
      7. fever
      8. abnormal nocturnal/diurnal sleep patterns
      9. patient’s occupational history, including current and past exposures, environmental, smoking (active and passive), travel, and family respiratory tract history, including:
      10. a history of allergies, previous respiratory tract diseases, and previous PPD, TB, and BCG status
      11. the risk for alpha 1 antitrypsin deficiency
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
      1. assessing the use of accessory muscles for breathing
      2. inspection, palpation, percussion and auscultation of the chest discriminating the following:
      3. recognizing and differentiating abnormal lung sounds, such as wheezing, rales, and rhonchi from normal breath sounds.
      4. differentiating between a normal, dull and hyperresonant chest by percussion.
      5. differentiating between areas of consolidation and pleural fluid by assessing the quality of the breath sounds and ancillary findings such as egophony and whispered pectoriloquoy
      6. assessing the prescence of pleural friction rub.
    3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis, recognizing specific history and physical exam findings that confirm or refute a diagnosis of asthma, chronic bronchitis, or emphysema
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests, when appropriate, should include:
        • chest x-ray to recognize x-ray patterns that suggest asthma, bronchitis, and emphysema
        • basic pulmonary function tests (such as ABG, pulmonary function tests, and spirometry) used to evaluate respiratory tract diseases
        • interpretation of a gram stain of sputum
        • pulse oximetry
    5. communication skills: Students should be able to:
      1. communicate the diagnosis, prognosis and treatment plan of the disease to patients and their families, taking into consideration their knowledge of the disease and their treatment preferences
    6. basic procedural skills: Students should be able to perform:
      1. gram stain of sputum
      2. arterial blood gases
    7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including:
      1. the basic principles of oxygen, antibiotic, bronchodialator, and corticosteroid therapy
      2. the basic bronchodialator and corticosteroid management when appropriate
      3. the steps in a critical pathway for patients hospitalized with COPD exacerbations
      4. smoking cessation strategies
      5. accessing and utilizing appropriate information systems and resources to help delineate issues related to COPD
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. recognize that poor working, living, and environmental conditions can contribute to respiratory tract disease