PULMONMARY MEDICINE MODULE: 2006/7

CURRICULUM: YEAR 4 & 5 UNDERGRADUATE MEDICINE

Course description

Title: Pulmonary Medicine: Year 4&5 Undergraduate Medicine

Overview
This course is designed to complete the training of the medical undergraduate student
in pulmonary medicine within the context of general internal medicine over two
rotating 8 weeks clerkships.

Prerequisite
A pass in the MB:BS Phase 1 examination.

Organisation of the Course

The course is taught in two modules
1. Year 4 - at the Eric Williams Medical Sciences Complex (EWMSC), and San
Fernando General Hospital
2. Year 5 - at Port of Spain General Hospital
depending on availability of personnel and consistent with the service commitment of
the medical teachers involved.

Integration within the Undergraduate Programme in Medical Sciences

Pulmonary medicine is one of several components of general internal medicine with
which the student is expected to become familiar over the two final years of
undergraduate training in the Faculty of Medical Sciences and integrates closely with
other sub-specialties including cardiology, cardiothoracic surgery and intensive care
medicine. Over the course of the final 2 years of undergraduate training, students are
expected to become familiar with the management of pulmonary diseases within and
across these specialties.

Pulmonary Medicine as a Discipline within Internal Medicine

The Department of Clinical Medical Sciences is comprised of four units: Adult
Medicine (General Internal Medicine), Paediatrics and Radiology. Pulmonary
medicine is one of several disciplines within internal medicine.

Purpose of the Course

The course covers diseases of the chest or respiratory system and is also called
pulmonology, respirology, respiratory medicine, and pulmonary medicine or chest
medicine. Students would be expected to have been exposed to the rudiments of the
chest examination and history during Phase I training. This course is designed for
students during the final two clinical years of undergraduate medicine.

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At the end of the course, the student will be expected to diagnose and treat the
following major common pulmonary conditions: asthma, COPD, lung cancer,
pneumonia, pleural effusion, tuberculosis, pulmonary embolism. The student will also
be expected to understand the differential diagnosis of these conditions and how to
differentiate between these and other medical conditions by laboratory and
radiological investigations.

Letter to the Student

Welcome to the Pulmonary Medicine component of the Internal Medicine

Programme. We hope that you will see this course as an extension of the learning
initiated during your first three years of training. Whereas in the first year of internal
medicine (year 4 undergraduate) we emphasised knowledge of the underlying disease
processes and the acquisition of an accurate history and examination, our emphasis in
the final year is on diagnostic skill, investigation and treatment of common pulmonary
diseases and their differentiation from other diseases. The best advice we can give you
is that learning is patient-centred and not text-book centred, though your text books
will provide a useful resource. We hope you enjoy your brief time with us in this
exciting field.

Contact Information

Tutors: EWMSC - Dr. T. Seemungal, Dr. D. Coomansingh, Dr. S. Teelucksingh and

Associate Lecturers from Thoracic Medicine Unit.
Port of Spain General Hospital – Dr. T. Seemungal, Dr. S. Teelucksingh and
Associate Lecturers from the Department of Medicine at POSGH
Office: Department of Clinical Medical Sciences, Faculty of Medical Sciences, 2nd
Floor, Building 67, EWMSC, Mount Hope
Contact Phone: Department of Medicine EWMSC 663 4332;
POSGH 623-4030 or ext 2585
E-mail: tseemungal@aol.com

Content

Clinical presentation of pulmonary diseases

Dyspnoea, cough, sputum, haemoptysis, wheeze, chest pain, fatigue, sleep
disturbance, excessive snoring, confusion, ankle oedema, hoarseness, night sweats.
The student is expected to characterise each of these symptoms by onset (where, when
how), duration and evolution. Common causes of each of these symptoms.

Symptom severity:
Dyspnoea: MRC dyspnoea scale, New York Heart Scale,
Sputum: volume and purulence
Haemoptysis: clinical significance and management of massive haemoptysis. Causes
of haemoptysis – PE, LRTI, Tb, lung cancer, bronchiectasis, aspergillosis

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Chest pain: severity, location of pain in relation to cause, pleuritic chest pain

Chest History
Past Medical History: importance of comorbidites eg cardiac, diabetes
Drug History: importance of retrospective diagnosis of lung disease from the drug
history. Adverse effects on the lung – ACEIs, beta-blockers, NSAIDs, drugs causing
pulmonary fibrosis
Allergy history and relation to chest diseases esp. asthma, angioedema
Smoking – definition of a pack year as a measure of smoking burden
Family – genetic basis of some lung diseases – cystic fibrosis, alpha-1 antitrypsin
deficiency, familial diseases
Occupational lung disease: occupational asthma, dusts and COPD, air pollutants and
cardiopulmonary diseases eg effect on heart rate variability
Social: disease and socio-economic status eg Tb, COPD, compliance
Pet history: pet related lung diseases: asthma, extrinsic allergic alveolitis

Signs of Pulmonary Disease

(a) The following signs are of special importance in pulmonary medicine-

cyanosis - definition, detection, causes
clubbing. – definition, causes, HPOA
flapping tremor and respiratory failure
(b) Examination of the skin, pulse, joints,
JVP - characteristics of the JVP, differentiation from carotid pulse,
relationship to SVC obstruction, cardiac tamponade, tricuspid
incompetence
Lymphatic system - causes of lymph node enlargement
(c) Inspection, palpation, percussion and auscultation of the chest. Interpretation
and reporting of these signs will be emphasised.

Investigation of Pulmonary Diseases

I. Chest radiograph: characteristics of the various chest diseases in this syllabus

Spirometry:

Definition: FEV1, FVC, IC, FEV1/FVC ratio, PEFR, FEF25-75

Measurement of variables
Indications

II. Arterial blood gases:

Technique of taking ABG, technique of local anaesthetic, Allen’s sign,
Interpretation of ABG and the Henderson-Hasselbach Equation,
Biochemistry of measurement of pH, CO2, O2, HCO3.

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 A-aDO2 gradient.
III. Bronchoscopy and bronchial biopsy
Indications, procedure, complications, risks, sedation, recovery, type
of sampling of the lower airway: mucosal biopsy, TBLB, Washings,
BAL
IV. Thoracentesis: indications, procedure, complications.
V. Pleural biopsy: indications, contraindication, risks, positioning of the patient,
site selection, technique, use of Abram’s needle,
VI. CT Scanning and CT guided biopsy
VII. Static lung volumes: definition, indications, VC, TLC, RV, FRC, factors
affecting each, body plethysmograph, anatomic dead space, RAW,
VIII. Gas transfer : indications, definition, DLCO, alveolar volume, KCO, factors
affecting each, methods of measurement.
IX. Lung Tissue analysis: Bronchoscopic biopsy (mucosal, TBLB), percutaneous
biopsy, thoracoscopic biopsy, open lung biopsy. Indications and complications
of each.
Special emphasis will be placed on investigations I, II, III, VI above.

Specific Diseases of the Lung

In the final year several further diseases will be discussed in addition to those studies
during the fourth year:
(1) through (5) – Year 4; All topics in Year 5
(1) Asthma
a. Definition and prevalence
b. Aetiology: genetics, triggers:- smoke, pollutants, allergens.
c. Clinical presentation: acute severe asthma, episodic asthma, chronic
(persistent) asthma
d. Specific points in the history: family history, atopy, effects of aspirin,
NSAID or beta-blocker use, allergens
e. Objective measurements of lung function as PEFR, FEV1, FVC: (i)
diurnal variation, (ii) after use of beta-2 agonist inhalers or nebulisers
or steroid treatment (iii) after exercise. ABG and SaO2 measurements –
indications and interpretation.
f. Subtypes of asthma: allergic, exercise, occupational
g. Differential diagnosis
h. The management of acute severe asthma: Nebulisers, steroids, IV
drugs, role of arterial blood gas analysis[respiratory alkalosis, the
asthmatic with a normal or elevated PCO2], indications for a chest
radiograph
i. Ward management: When to discharge, PEFR monitoring, training in
use of inhaled medications.
j. Intensive care: indications, discharge.
k. Community management of asthma: PEFR monitoring, grades of
asthma severity, GINA guidelines. Goals in treatment of asthma in the
community: abolition of symptoms, prevention of asthmatic

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 exacerbations, life style issues.
l. Asthma Therapeutics:
Delivery devices – spacers, MDIs, Dry powder devices
Reliever medications - beta-2 agonists short and long acting
Preventer medications: long acting beta-2 agonists, inhaled
steroids, LTRAs, PDE inhibitors, Omalizumab
Avoidance measures: Allergens, smoking, dampness,
Pollutants, respiratory viruses

(2) COPD
a. Prevalence. Definition – role of spirometry
b. Aetiology: active smoking, smoking burden, genetics
c. Clinical presentation: cough and sputum, dyspnoea, acute exacerbation
d. Signs: hyperinflation, weight loss, signs of respiratory failure (central
cyanosis, flapping tremor, bounding pulse), pedal oedema, signs of
pulmonary hypertension (raised JVP, loud P2, tricuspid regurgitation)
e. Differential diagnosis
f. Investigations: spirometry, static lung volumes (air trapping),
reversibility testing, chest radiograph, arterial blood gas analysis
(normal, acute respiratory acidosis, compensated type 2 respiratory
failure), ECG, FBC
g. Treatment of Acute Exacerbations of COPD: nebulisers, steroids,
antibiotics, controlled oxygen therapy, diuretics, physiotherapy, non-
invasive ventilation
h. Treatment of COPD in the community: goals in treatment, smoking
cessation strategies, beta-2 agonists, anticholinergics, theophyllines,
inhaled steroids, PDE inhibitors. Other: exercise, nutrition,
vaccination, ambulatory oxygen, pulmonary rehabilitation.

(3) Pneumonia
a. Definitions of pneumonia in the community and in hospital
b. Classification of pneumonias: CAP, Nosocomial, aspiration, relapsing,
pneumonia in the immunocompromised, geographical
c. Pathogens
d. Incidence and mortality
e. Clinical presentation
f. Signs
g. Differential diagnosis: asthma, CCF, IHD, pneumothorax, pleural
effusion
h. Investigations
(i) FBC, U&E, LFTs, CRP, ESR, ABG
(ii) sputum, blood cultures, urine tests
(iii) serology
(iv) Radiology
i. Prognostic factors: age, comorbidity etc
j. Complications: lung abscess, Empyema, screening for lung cancer

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 k. Treatment of community acquired and nosocomial pneumonia
(i) treated in the community
(ii) admitted to hospital: nursing care, drugs, fluids,
l. Follow-up management: CXR, lung function. When are they indicated?

(4) Pleural Effusion

a. Overview of diseases of the pleura: effusions, mesothelioma, pleural
thickening, pleural secondaries
b. Definition
c. Aetiology
d. Clinical presentation
e. Signs
f. Differential diagnosis
g. Investigations:
Radiology: characteristics of the CXR, indications for CT scanning
Thoracentesis: Diagnostic implications of appearance of fluid
Microbiology, cytology,
biochemistry - protein, LDH, pH, other depending on
suspected cause. LIGHT’S CRITERIA.
Need to compare with blood values
Needle biopsy – see above
Thoracoscopy, thoracotomy
h. Transudate vs. exudate and their causes
i. Tube drainage
j. Treatment of an empyema

(5) Lung Cancer

a. Bronchogenic carcinoma
(i) Definition
(ii) Incidence, aetiology and risk factors: sex, genetics, active
and passive smoking and pollutants, radiation,
occupational exposures
{asbestos, nickel, arsenic, silica, radiation, hydrocarbons}
(iii) Clinical presentation
(iv) Signs
(v) Non-metastatic extra-pulmonary manifestations
(vi) Investigation: sputum, CXR, CT Scan,
(vii) Investigation – bronchoscopy: (washings, brushings,
biopsy),
Indications: Persistent cough, Dyspnoea, Haemoptysis,
Abnormal CXR, Inhalation of a foreign
object, Dx of asthma, lung ca, bronchitis,lung
inf, examine a congenital deformity
Contraindications: Unstable low BP, Arrythmias, Recent
heart attack or heart disease, Bleeding
problems, Allergy to lidocaine, Unstable

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 asthma, Restricted TMJ
Major Complications (0.5%): Respiratory depression,
Pneumonia, Pneumothorax, Airway
obstruction, Cardiorespiratory distress,
Arrhythmias, Pulmonary oedema, major
haemorrhage.

Minor Complications : Vasovagal Reactions, Fever,

Arrhythmias, Haemorrhage, Airway
obstruction, Pnuemothorax, nausea and
vomiting
(viii) Surgical biopsy
(ix) Histologic classification of bronchogenic carcinoma
(x) Staging of large and small cell tumours
b. Other tumours - clinical presentation, diagnosis and outline of
management strategies:
(i) other primary lung tumours including alveolar cell
carcinoma, adenocarcinoma
(ii) secondary tumours of lung,
(iii) mesothelioma,
(iv) mediastinal tumours

(6) Venous thromboembolism: Pulmonary embolism, DVT

a. Incidence and aetiology, risk factors
b. Clinical Presentation: acute massive PE, submassive PE, acute PE
c. Differential diagnosis
d. Investigation: CXR, ABG, V:Q Scan, CT-pulmonary angiogram
e. Treatment of acute PE and massive PE
Anticoagulation: heparins: unfractionated heparin, LMWH,
duration of heparin, treatment, overlap with
warfarin. Adverse effects including
thrombocytopaenia
Warfarin: indications, adverse effects, duration of therapy,
monitoring, drug interactions

Early discharge management plans

f. DVT: diagnosis and treatment

(7) Tuberculosis
a. Definition
b. Clinical epidemiology of TB: West Indies, world-wide, why TB is an
important public Health problem. The five most common causes of
death world-wide.
c. Clinical presentation of tuberculosis; pulmonary TB, extra pulmonary
manifestations: lymph node TB, tuberculous meningitis, other.
d. Risk factors: diabetes, immunodeficient states including AIDS/HIV –

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 tuberculosis as an AIDS defining illness.
e. Diagnosis: may be clinical but importance of bacteriological diagnosis.
Sputum, bronchial specimens, gastric lavage (children), biopsy
f. Clinical descriptions of TB cases: ‘smear positive’ and ‘sputum smear
positive’ TB.
g. Differential diagnosis
h. Notification and Public Health Law
i. Organisation of TB services
j. TB treatment: drug sensitivity is always required, use of 4 drugs,
interactions, drug resistant TB, DOT
k. Prevention and Control of TB: control of TB in hospitals, Contact
tracing and examination of contacts: Mantoux, Heaf tests, Chest
radiograph. BCG vaccination and chemoprophylaxis.
l. Bovine TB, opportunistic mycobacterial infection eg MAI

(8) Other Granulomatous lung diseases: sarcoidosis, Wegener’s, Goodpasteur’s,

fungal infection, other.

(9) Diffuse parenchymal lung disease – basic investigative strategies. Treatment

of IPF:
a. Acute disease: infection, allergy, ARDS
b. Episodic: pulmonary haemorrhage, Churg-Strauss, EAA, COP
c. Chronic disease: Occupational, drugs (amiodarone, bleomycin,
methotrexate, paraquat), systemic disease (SLE, Sjogren’s, RA,
lymphangitic carcinoma), cryptogenic fibrosing alveolitis (idiopathic
pulmonary fibrosis - IPF), chronic aspiration, pulmonary veno-
occlusive disease. Classification of IPF.

(10) Other diseases of the pleura and chest wall

a. Spontaneous Pneumothorax: Treatment options, tension pneumothorax
b. Mesothelioma: asbestosis exposure
c. Kyphoscoliosis as a cause of respiratory failure
d. Ankylosing spondylitis

(11) Sleep disturbances

a. Definition and differential diagnosis of persistent sleepiness
b. Apnoeas: central vs obstructive
c. Clinical presentation of OSA, Epworth Scale
d. Risk factors. Relationship to the metabolic syndrome.
e. Diagnosis of OSA
f. Treatment: behaviour modification, nCPAP, surgery and oral devices,
tracheostomy. Pharmacotherapy- modafinil.

(12) Respiratory Failure

a. Definition and types of respiratory failure
b. Causes and treatment of Type I respiratory failure

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 c. Causes and treatment of acute Type II respiratory failure.
d. Acute on chronic Type II respiratory Failure
- Definition
- Causes
- Assessment and treatment
e. Oxygen Therapy
- What is FIO2?
- Natural of chronic hypoxaemia (rationale of treatment)
- Adverse effects of oxygen
- Methods of administration
f. Ventilation:
- Definition
- Invasive vs non-invasive: advantages and indications

In the study of each of these diseases, the principles of history taking and examination
will be emphasised.

Students will be expected to be able to describe the investigation of these diseases and
the principles of management and knowledge of drugs used where applicable.

Specific details of management including doses of drugs used will be required for
acute severe asthma and acute pulmonary embolism. The role of the intensive care
unit in the management of acutely decompensated pulmonary diseases will be
discussed.

Goals/ Aims

The knowledge base developed during the year 4 training in internal medicine will be
expanded in year 5. All diseases discussed during year 4 will be reviewed during
bedside sessions and a few other pulmonary diseases will be discussed.

Seven very common pulmonary diseases have been chosen for the core pulmonary
medicine in your syllabus. Patients with these diseases should be easily clerked on the
medical wards of San Fernando General Hospital and Port of Spain General Hospital
or chest wards at the EWMSC. These diseases of the lungs will be discussed in terms
of disorders of the airways, lung parenchyma or pleura in order to illustrate a simple
model of understanding pulmonary diseases.

Students will be expected to attend the Medical Grand rounds at the POSGH during
their training at POSGH and to answer simple questions about the cases discussed
during these sessions.

Students are expected to be aware of the latest therapeutic strategies employing

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evidence-based medicine. This information may be accessed via the various approved
websites.

By the end of their 2 years’ training in pulmonary medicine, students will expect to
have reached an internationally accepted standard in their knowledge and
management of pulmonary diseases within general internal medicine.

General Objectives

At the end of the course you will be expected to

1. understand how to elicit a history of pulmonary diseases
2. be able to elicit the signs of pulmonary diseases
3. state a differential diagnosis for each symptom of pulmonary disease
4. know the causes of clubbing and cyanosis and the differential diagnosis
of cyanosis
5. demonstrate time management within the program
6. demonstrate empathy and caring toward your patients
7. submit a short project

Structure of the course: teaching vs bedside learning

The years 4& 5 pulmonary medicine module consists of 1 session per week for 8
weeks either at POSGH or at EWMSC. You will be provided with a sessional
timetable at the start of the course.

Specific Objectives

At the end of the course you will be able to

1. define the symptoms and signs of pulmonary

disease
2. state common causes (pulmonary and non-
pulmonary) of each symptom or sign mentioned above
3. define each of the major diseases in this
syllabus
4. integrate the symptoms and signs of pulmonary
disease with the clinical presentation of each of the pulmonary
diseases studied in this course
5. differentiate between the different conditions using the history,
examination and investigations discussed during this course
6. state the treatment of acute asthma and acute PE
7. discuss treatment options of pulmonary diseases
8. differentiate between tuberculous infection and tuberculous
disease in clinical presentation and management

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 9. discriminate between different arterial blood gas results and
their causes
10. use abnormal spirometric results in the differential diagnosis of
chest diseases
Assignments

1. The student will expected to clerk at least 1 patient with each of the first 7
pulmonary diseases described in the content section above and to present and
discuss each case with any instructor. Clerking of a patient will involve
a. Presenting compliant
b. Complete history
c. Examination of all systems of the patients with special
emphasis on the chest examination
d. A description of what investigations were done and
should be done with details of results where applicable
e. Treatment and response to treatment
f. Follow-up plan for the patient including discharge
2. Students may be given a short project

Assessment/ Evaluation

The purpose of the assessment would be to help you to appreciate where you have
reached in attaining the goals set out in this syllabus and to stimulate you to continue
to study internal and pulmonary medicine.
Your assessment will take the following forms
(1) A written examination based on structured questions or MCQs
(2) Evaluation of a project and coursework
(3) Grading of cases clerked
Teaching Strategies
The Department of medicine employs several teaching strategies which will include
1. guided lectures,
2. bed side teaching,
3. small group teaching,
4. non-lecture strategies: projects, group discussions, role play, co-operative learning

Resources
1. Patients on the medical and surgical wards, POSGH, are our most valuable
resource.
2. Patients in the medical outpatients’ clinics.

Readings

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1. Davidson’s Principles and Practice of Medicine: respiratory medicine chapter.
2. Kumar and Clarke: respiratory medicine chapter.
3. West JB. Respiratory physiology – the essentials.
4. Approved Websites: ATS (Amer Thoracic Society), ACCP (Am College of Chest
Physicians), NIH (Nat. Institute of Health USA), NICE (Nat. Institute of Clinical
Excellence), SIGN (Scottish Intercollegiate Guidelines Network), BTS (Brit Thoracic
Society), ERS (Eur Resp Soc), PUBMED.
Other website should be discussed with the instructor before use.

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