Musculoskeletal

Cell Phone 347-394-5525 (text is best)

Rotation Preparation:

• Review the information below, your weekly schedule (Orange schedule) and the MSK dashboard a week before starting so that you are familiar with your schedule and rotation expectations.

• Please email your preceptors introducing yourself one week before you start the rotation and to get an updated preceptor schedule. 

• Please show up to all clinical experiences.

• Be prepared for Wed MSK Clinic sessions - read up on your patients, set up appropriately, and complete notes in a timely manner.

• Notify Dr. Shah via text at 347-394-5525 and the chiefs via email if you cannot be present for any expected activities.

• For all clinical experiences outside of Farrell, please present yourself professionally wearing proper attire and a pressed white coat, and please be respectful of your preceptors. 

Further details, reading, and board-style questions can be found here: MSK DASHBOARD

Description: Physical medicine and rehabilitation, also known as physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. You will hone your exam skills, see in-depth procedures, and learn "the next step above MSK." 

Location: Harkness 1st floor Rehab Suite. 

Contact: Cindy Volack, Program Coordinator at #212-305-8592 or volackc@nyp.org and Dr. Smith directly at cs3028@columbia.edu , https://columbiadoctors.org/prof/ccsmith, 

Notes: Professional dress including clean white coat is mandatory. Be on time.

Description: Evaluation and management of rheumatologic issues, many of which you will see in your day-to-day primary care practice, inpatient medicine, and in the FHC MSK clinic. 

Location: Irving Pavilion (161 Fort Washington Ave.) 2nd Floor, room 205. 

Contact: Dr. Teja Kapoor - tmk2134@cumc.columbia.edu, cell: 732-910-6683, office: 212-305-4308

Notes: Ask lots of questions to get the most out of your rotation. Professional dress including a clean white coat is mandatory. Be on time.

 Please refer to the supplemental learning information given by Dr. Kapoor: 

https://drive.google.com/drive/folders/1uKL2mUlH95Sxb7ObkOjPfxtydqLDMikT?usp=sharing. 

You can also access Rheumatology Secrets by Sterling West via Columbia Libraries.

Description: Evaluation and management of common primary care MSK issues and patients with acute and chronic pain. 

Location: Farrell Health Center, 2nd floor 

Contact: Dr. Julie Berenyi, DO - email: jbb2176@cumc.columbia.edu

Notes: Please look up all of your patients and be on time.

Description: Learn osteopathic medicine principles and techniques including hands-on manipulation that can be incorporated into a primary care. 

Location: FHC 

Contact: Dr. Julie Berenyi, DO - email jbb2176@cumc.columbia.edu.

Description: See a variety of common MSK complaints and evaluate and treat them using various modalities including US-guided injections and arthrocentesis in a more private practice medical setting. 

3rd and 4th Friday AM of the rotation.

Location: 590 Fifth Ave (walk straight through past security – no need to check in with them – to the elevators and head up to the 5th floor)

Contact: Dr. Goldwaser - text him - 201-650-5533, general questions can be emailed to the office coordinator, Jessica Ronqueni jr3631@cumc.columbia.edu

Notes: Clinic starts sharply at 7:40 AM, please be on time and dress wearing scrubs or professionally with a clean white coat.  

Two Fridays per month - email Dr. Kapoor if interested.

Note: you can only go to these sessions on QI/R3P Fridays.

Rotation Expectations:

• See Rotation Preparation above.

• Complete one set of the MSK board style questions found on the dashboard.

• Watch the exam videos posted on the dashboard and learn the exams for the shoulder, knee, back, and hips.

• Read at least one article a week - see MSK Dashboard. You and Dr. Berenyi can create a reading list tailored to you.

PREPARATION 

1. Pre-read on all patients. Know who referred, when and why. 

2. Bring a retractable pen with you to clinic (for marking injection sites and trigger points). 

3. Collect all supplies prior to your first patient – 1% lidocaine without epi & 40mg/cc triamcinolone from the RN, ethyl chloride spray from the clean utility room downstairs (door code is 234) 

4. When you open a new bottle of medication (lido or triamcinolone) put an expiration date tag on it 30 days from when it was opened. 

WHEN YOU SEE THE PATIENT 

1. Document which body part the patient is getting injected and why, rate the patient's pain prior to the procedure as well as post-procedure.

2. All patients should be asked to change into a gown unless it’s a simple follow-up that does not need an examination. 

3. Ensure you obtain all components of a usual HPI – location, onset, quality, severity, timing, duration, alleviating / exacerbating factors, meds taken, if they have had imaging or PT or other consultant evaluations. 

4. Keep a log of your procedures. 

5. Do your best to understand the anatomy of the area being discussed (by pulling up pictures on Google images) while / after you talk with the patient. 

6. Clean up after each and every procedure – sharps in sharps container, meds and supplies LOCKED in the cart. Use a chuck if the procedure is going to be messy. 

NOTE WRITING and END OF SESSION 

1. In the chief complaint section, start with “MSK: Low back pain, new/follow-up patient, referred by Dr. XX” 

2. Exams should include comments on inspection, palpation, ROM, strength, stability, and special tests. 

3. Place procedure notes in the under the physical exam section. 

4. If a procedure is done by the preceptor, note in your plan that “x procedure was done by Dr. xx, see procedure note above.” You are not responsible for these procedure notes. 

5. Ensure you state a clear follow-up plan in your note. 

6. Return all meds to the appropriate places (ok to give ethyl to the MA if you don’t have time.) 

7. Try to complete all notes and superbills by the end of the day, within 24 hours at the latest. 

8. No show notes should mention “MSK Clinic” somewhere. 

FOLLOW UP 

1. You are in charge of the studies/labs you order. When the result returns to your inbox, even when you’re off rotation, you need to write a quick results note (ok if it’s incomplete) indicating the study was ordered in MSK Clinic and send it to your preceptor. This will ensure follow-up of all studies and great patient care! 

Rotation Assignments:

• Complete one set of the MSK board style questions found on the dashboard.

• Watch the exam videos posted on the dashboard and learn the exams for the shoulder, knee, back, and hips.

• Read at least one article a week - see MSK Dashbaord. You and Dr. Shah or Dr. Berenyi can create a reading list tailored to you.

Recommended Readings will be assigned to you. 

• See MSK dashboard reading list and "Other Resources" below.

Rotation Feedback and Evaluation:

•  Residents will briefly check in via email with Dr. Shah during the last week to discuss any concerns, questions, and provide rotation feedback.

• Residents are expected to complete rotation evaluations on Mehhub which are anonymous and will be reviewed every 6 months.

Books:

1)      Green W, Griffin L Y ed. , Essentials of Musculoskeletal care. 3rd ed. Rosemont,II : American Academy of Orthopaedic Surgeons;2005.

2)      McKeag DB, Moeller JL. ACSM’s primary care sports medicine, comprehensive sports medicine references geared to primary care practitioners. 2nd ed. Philadelphia,Pa: Lippincott, Williams & Wilkins, 2007.

3)      ACSM’s Guidelines for exercise testing and prescription. 7th ed. Baltimore, MD: Lippincott, Williams & Wilkins, 2005.

4)      Eiff MP, Hatch RL, Calmbach WL, Hatch RL. Fracture management for primary care. 2nd ed. Philadelphia, PA: Saunders, 2002

5)      Reider B. The Opthopaedic physical examination. 2nd ed. Philadelphia, PS: Elsevier Saunders: 2005

6)      Hoppenfeld S. Physical examination of the spine and extremities. 1st ed. New York, NY: Appleton & Lange; 1976

7)      McNabb, James.  A Practical Guide to Joint & Soft Tissue Injection & Aspiration. 2nd Ed. Lippincott Williams &Wilkins; 2010

8)      Anderson, Bob.  Stretching 20th Anniversary Revised Edition Shelter Publications Inc. 2005

9)      Travell & Simons’ Myofascial Pain and Dysfunction.  The Trigger Point Manual Volume 1.  Upper Half ot Body. 2nd Edition, 199.   Lippincott Williams & Wilkins.

10)  Travell & Simons’ Myofascial Pain and Dysfunction.  The Trigger Point Manual.  The lower extremities, 1993.  Lippincott Williams & Wilkins

Web-based resources: 

1.) Lippincott’s Orthopedics for Primary Care (online) @ www.orthopedicsforpcp.com

Username: mskfarrell1

Password: mskfarrell2

2) American College of Sports Medicine: http://www.acsm.org

4) Massachusetts General Hospital, Musculoskeletal Disorders:  http://www.massgeneral.org/children/adolescenthealth/articles/aa musculoskeletal disorders.aspx

5) Preparticipation Physical Evaluation Monograph, 3rd Edition, 2004 McGraw-Hill Healthcare Information Group: http://www.aafp.org/fpr/20040800/6.html

6) The Physician and Sports Medicine: http://www.physsportsmed.com

7) University Hospitals of Cleaveland Department of Radiology, Online Musculoskeletal Radiology Teaching Cases (musculoskeletal cases with description and image files): http://www.uhrad.com/msiarc.htm

8) University of West Alabama Department of Sports Medicine and Athletic Training, Online Musculoskeletal Exam List and Explanation with Video (join-specific physical exam test listing with detailed explanations and short video clips of the exam being performed): http://at.uwa.edu/currHome/AH323/skillsshoulder.asp

Articles

1)      Cassas KJ, Cassettari-Wayhs A. Childhood and adolescenet sports-related overuse injuries. AM Fam Physician 2006;73:1014-22. – http://www.aafp.org/afp/20060315/1014.pdf

2)      Geise EA, O Connor FG, Brennan FH, Depenbrock PJ, Oriscello RG. The athletic preparticipation evaluation: cardiovascular assessment. Am Fam Physician 2007; 75(7):1008-14  - http://www.aafp.org/afp/20070401/1008.pdf

Organizations

American Academy of Family Physicians: http://www.aafp.org

American Academy of Orthopaedic Surgeons: http://aaos.org

American College of Radiology: http://acr.org

American College of Rheumatology: http//www.rheumatology.org

American College of Sports Medicine: http://www.acsm.org

American Medical Society for Sports Medicine: http//www.newamssm.org

American Orthopaedic Society for Sports Medicine: http//www.sportsmed.org

Arthritis Foundation: http://arthritis.org

1. Begin learning the basic anatomy, evaluation, examination skills, radiologic interpretation of core MSK body areas (neck, shoulder, elbow, hand, hip, low back, knee, ankle). (MK-2)

2. Understand and begin applying principles of treatment, including but not limited to heat/ice, PT/movement/exercise, NSAIDs/other pain Rx, corticosteroid injections and other types of injections, and writing a concise and appropriate PT referral as indicated by the patient's diagnosis (MK-2).

3. Identify appropriate materials needed for aspiration and corticosteroid injections as well as perform these procedures with appropriate technique with assistance. (PC-5)

4. Complete first set of board-style questions, review missed questions, and study a selection of key articles listed on the dashboard during the rotation.

5. Demonstrate professional conduct and accountability, which includes showing up on time, being prepared for all clinical encounters, participating in off-site sub-specialty visits, completing clinical and administrative tasks promptly, and following up on communication. Please ensure you wear a clean, pressed white coat to all off-site clincial experiences. (PROF-2)