Patient Care

Fibromyalgia

• Recognize the typical history and symptoms for a patient with fibromyalgia The American College of Rheumatology has published classification criteria for fibromyalgia
• Demonstrate the characteristic tender points of fibromyalgia on examination
• Utilize the appropriate evaluation (8-9) tools in the diagnosis of widespread chronic pain
• Describe pharmacological and non-pharmacologic modalities of treatment (6-7)

Regional Musculoskeletal Disorders

• Demonstrate a complete physical examination of the shoulder, elbow, hand and wrist, hip, knee, foot and ankle, neck and low back including inspection, palpation, range of motion, strength testing and neurological evaluation
• Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the shoulder including: rotator cuff tendinitis, rotator cuff tear (1, 2, 3), impingement syndrome (1, 2), bicipital tendinitis, subacromial bursitis, subdeltoid bursitis, frozen shoulder (adhesive capsulitis), and thoracic outlet syndrome, and distinguish these from osteoarthritis of the glenohumeral joint and acromioclavicular joint
• Recognize the expected history, symptoms physical and radiographic examination findings associated with common disorders of the elbow including olecranon bursitis, lateral epicondylitis (tennis elbow), medial epicondylitis, and ulnar entrapment neuropathy
• Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the hand and wrist including Dupuytren’s contracture (1, 2, 3), trigger finger, de Quervain’s tenosynovitis, ganglion cyst, and carpal tunnel syndrome (median neuropathy) (1, 2, 3), and distinguish these from osteoarthritis of the hand
• Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders causing pain in the hip including trochanteric bursitis, ischial bursitis, iliopsoas bursitis, coccydynia, and meralgia paresthetica (entrapment of the lateral femoral cutaneous nerve), and distinguish these from osteoarthritis of the hip
• Recognize the expected history, symptoms and physical examination findings associated with common disorders of the knee including anserine bursitis, chondromalacia patella, prepatellar bursitis, meniscal tear (1, 2, 3), and tear of the anterior and posterior cruciate ligaments (1, 2), and compare these to osteoarthritis of the knee
• Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the foot and ankle including plantar fasciitis, retrocalcaneal bursitis, Achilles tendinitis (1, 2, 3), hallux valgus and bunion formation (1, 2), Morton’s neuroma, and metatarsal stress fracture , and distinguish/compare these to osteoarthritis of the foot
• Recognize the expected history, symptoms and physical examination findings associated with common disorders of the neck and cervical spine including cervical strain, degenerative disc disease and herniated disc syndromes (1, 2), cervical spinal stenosis, and cervical myelopathy
• Recognize the expected history, symptoms, physical and radiographic examination findings associated with common disorders of the low back and lumbar spine including back strain, degenerative disc disease and herniated disc syndromes (1, 2, 3), radiculopathy, lumbar spinal stenosis (1, 2), and cauda equina syndrome
• Review the expected history and risk factors, symptoms and physical examination findings for complex regional pain syndrome (reflex sympathetic dystrophy) (1, 2, 3) and a neuropathic joint (Charcot joint) (1, 2, 3)
• Identify the appropriate evaluation and diagnostic studies, including radiography, related to each of the above entities
• Describe the therapeutic options, including the appropriate indication and associated cost of the above entities including pain medications, physical therapy, splinting, local injection, and surgical referral
• Identify the appropriate approach and method for intra-articular and soft tissue glucocorticoid injections

Medical Knowledge

• Review normal structure of a diarthrodial joint (1, 2) and vertebral body
• Review the normal joint structure and radiographs of the hand (1, 2), wrist (1, 2, 3), elbow (1, 2, 3), shoulder (1, 2, 3), cervical spine (1, 2, 3), lumbar spine (1, 2, 3) , hip (1, 2), knee (1, 2, 3) , ankle (1, 2, 3), and foot (1, 2, 3), including major muscle groups, tendons, bursae, vascular structures, and innervations
• Identify both inflammatory and non-inflammatory causes of widespread chronic pain and relate distinguishing differences
• Recognize common areas for bursitis and tendinopathy, including trochanteric bursitis and adhesive capsulitis
• Identify causes of neck and back pain, including spondylosis, spinal stenosis, and spondylolisthesis
• Summarize basic indications and contraindications to musculoskeletal plain radiography, ultrasound, computerized tomography, and magnetic resonance imaging
• Review basic indications, components, and the potential complications for localized injections
• Contrast physical and occupational therapy including basic indications and modalities available (1, 2, 3)

Interpersonal and Communication Skills

• Explain the anticipated course and choices of therapy and the rationale for intervention, including the potential risks and benefits in a patient centered approach
• Review lifestyle modification which may limit or enhance recovery
• Acknowledge and include family and social support as designated by the patient
• Provide reassurance and adequate time and accessibility to address patient concerns
• Discuss treatment recommendations with other physicians and healthcare providers involved in the care of the patient

Professionalism

• Display integrity and honesty in discussing patient care issues and management
• Ensure patient privacy
• Promote patient autonomy in clinical and therapeutic decisions
• Communicate in a timely fashion regarding study results
• Provide adequate time and accessibility to address patient concerns
• Communicate in a timely fashion with the other members of the patient’s health care team
• Serve as the patient’s advocate

Problem-Based Learning

• Utilize web-based resources to supplement and update current knowledge base and to explore patient-specific problems.
• Incorporate evaluation and feedback into practice and management.
• Utilize errors and complications to improve understanding and future management.
• Set learning goals in diagnostic strategies and management.

System-Based Practice

• Identify barriers to accessing optimal medical care for each individual patient and utilize alternative resources when available to overcome these barriers
• Engage and incorporate the input of all medical providers including other physicians, the nursing staff, and physical and occupational therapists as necessary
• Serve as a source of learning and education for other members of the health care team for the patient
• Utilize the existing health care system to support and establish patient care goals
• Incorporate considerations of cost and risk-to-benefit ratios in clinical evaluations, monitoring, and therapeutic decisions, for the individual patient
• Recognize the impact of both the diagnostic and therapeutic interventions on the health care system, both locally and globally