Download Rheumatology - Danbury Hospital

Curriculum on Rheumatology
Danbury Hospital Internal Medicine Residency Program
Section Chief: Alla Rudinskaya, MD
Revised: April 7, 2013
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OBJECTIVES OF THE ELECTIVE
The objective of the rheumatology elective is to learn about all aspects of rheumatic diseases,
including arthritis and autoimmune diseases, clinical immunology, medical orthopedics,
crystalline arthropathies, osteoporosis, Lyme disease, systemic lupus, rheumatoid arthritis,
vasculitis and more. The emphasis of the rheumatology elective is to prepare the residents for
their career in Internal Medicine and Board certification. During the elective the residents should
improve their skills in diagnosing and managing rheumatologic conditions in the outpatient as
well as acute hospital settings. Comprehensive musculoskeletal examination, use of the
polarizing microscope, joint aspirate and injections are all emphasized.
Upon completion of the rheumatology rotation, the resident is expected to:
1) Understand the pathophysiology and proper management of patients with collagen vascular
disease.
2) Learn the approach to the care of patients with musculoskeletal disease.
3) Learn the diagnostic criteria for various rheumatologic disorders such as rheumatoid arthritis,
systemic lupus erythematosus, fibromyalgia, vasculitis, myositis and others.
4) Understand the proper use of medications for rheumatic diseases such as NSAIDS, analgesics,
corticosteroids, disease-modifying drugs, biologic agents and experimental treatments.
5) Perform in-house rheumatology consultation.
6) Perform joint aspirate & injections, tendon and bursal injections.
7) Discuss peer-reviewed literature.
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TEACHING METHOD
The resident is expected to participate in all aspects of care, including patient intake, interview,
examination, consultation and preventive care. During the elective the resident will participate in
the outpatient as well as in-hospital consultations and follow ups. The resident will report directly
to the attending rheumatologist on service. The resident is also expected to participate in the
community arthritis clinic on Main Street. During the elective the residents are expected and
encouraged to perform and discuss peer-reviewed literature.
Once a week a rheumatology attending attends residents morning reports to discuss inpatients
with rheumatologic conditions.
The rheumatology faculty participates in monthly noon conferences given to the house staff.
Opportunities to perform clinical research, roundtable lectures and case report / publications are
all encouraged

PROCEDURES/SPECIAL TESTING
During rheumatology elective the residents are expected to learn and master comprehensive
musculoskeletal examination, use of polarizing microscope, joint aspiration and injections.

READING LIST
1. Primer on the Rheumatic Diseases, Thirteenth Edition (provided to all rotating
residents)
2. MKSAP section of Rheumatology
3. Up-To-Date Rheumatology Chapters & References
4. Harrison’s Principles of Internal Medicine
5. Pub-Med search of all relevant journal articles pertaining to active patients.

RESIDENT SCHEDULE during rotation
Monday, Tuesday, Thursday and Friday, the resident attends morning report at 7:45-8:30 am.
On Wednesday morning the resident attends grand rounds at the hospital at 8:00-9:00 am.
9:00 am – 12:00 pm the resident works with one of the rheumatology attendings at the
rheumatology office at 33 Germantown Rd, Danbury.
12:00-1:00 pm the resident attends noon conference at the hospital
1:30 pm – 5:00 pm, the resident works with a rheumatology attending in the rheumatology
office.
Friday 9:00 am- 12:00 pm, the residents participates the Arthritis Clinic on Main Street under
supervision of a rheumatology attending.
If the hospital consultation is requested, the resident would be asked to evaluate the patient at
the hospital and report to the rheumatology attending.

TOPICS AND CONTENT:
The rheumatology faculty participates in monthly noon conferences given to house staff
in the cafeteria. The noon conferences are performed by Drs. David Trock, Alla
Rudinskaya, Michael Spiegel, Ken Miller, and Richard Roseff. A typical annual
curriculum includes the following lectures:
Rheumatologic Emergencies (given each summer): discuss major rheumatologic
emergencies, such as septic arthritis, temporal arteritis, CNS vasculitis, rheumatoid vasculitis,
pulmonary hemorrhage, catastrophic APS.
Rheumatoid arthritis: discuss etiology and epidemiology, clinical manifestations,
extraarticular manifestations, current DMARDs and biologic agents with emphasis on
potential side effects.
Systemic Lupus Erythematosus: update on etiology, clinical and laboratory
manifestations, discuss standard and novel treatment.
Vasculitis: discuss ANCA associated vasculitis, GCA, Takayasu’s arteritis,
polyarteritis nodosum, immune complex mediated vasculitis, Behcet’s disease, vasculitis
mimics.
Crystalline Arthropathies: gout, pseudogout, hydroxyapatite arthropathy,
miscellaneous crystals.. Discussing etiology, clinical manifestations and management.
Spondylarthropathy: ankylosing spondilitis, psoriatic arthropathy,
spondyloarthropathies associated with inflammatory bowel disease, reactive arthritis. Discuss
clinical manifestations and management, including role of DMARDs and biologic agents.
Lyme disease: epidemiology, stages of the disease: early localized, early
disseminated, late disease; diagnostic tests, treatment. Discuss other tick born diseases such
as ehrichiosis and babesiosis.
Metabolic Bone Disease & osteoporosis: discuss current guidelines for osteoporosis
screening, available treatment options, including bisphosphonates, SERM, teriparatide,
denosumab.
Bone Tumors: pigmented villonodular synovitis, synovial sarcoma, giant cell tumor,
octeosarcoma
Fibromyalgia & soft tissue rheumatism: clinical features, overlap with regional
syndromes, such as migraines, IBS, TMJ. Pharmacologic and nonpharmacologic
management.
Myositis & related disease : classification and clinical features, diagnostic tests,
including myositis associated and myositis specific autoantibodies, associated pulmonary
disease. Malignancy and myositis. Standard and experimental therapy.
Scleroderma & CREST syndrome: role of vasculopathy in pathogenesis of the
disease, clinical manifestations: skin, GI, pulmonary, renal, musculoskeletal, cardiac
involvement. Scleroderma renal crisis. Scleroderma-like disorders.
Sjogren’s syndrome: epidemiology, clinical features and assessment, extraglandular
manifestations.
Antiphospholipid syndrome: classification criteria, clinical manifestations,
laboratory features, catastrophic APS. Current guidelines on anticoagulation and pregnancy
management.
Osteoarthritis: epidemiology, clinical features, disease patterns and subsets.
Treatment: pharmacologic and nonpharmocologic management.
Rheumatologic manifestations of endocrine and other systemic diseases:
rheumatologic manifestations of diabetes mellitus, thyroid and parathyroid disease, Cushings
diasease, acromegaly. Rheumatologic manifestations of malignancy.
Each academic year one or two medical grand rounds lectures will be presented by
rheumatology faculty members.