Internal Medicine — Rotations
Community Medicine
Teaching
Site: Armed Forces Hospital
EPAs mapped to this activity
For residents in C
C1. Assessing, diagnosing, and managing patients with complex or atypical acute medical presentations | Required |
C3a. Providing internal medicine consultation to other clinical services - Part A: Patient Assessment and Decision-Making | Required |
C3b. Providing internal medicine consultation to other clinical services - Part B: Written consultation note | Optional |
C4a. Assessing, resuscitating, and managing unstable and critically ill patients - Part A: Patient Care | Optional |
C5. Performing the procedures of Internal Medicine | When Possible |
C7. Discussing serious and/or complex aspects of care with patients, families, and caregivers | Required |
C8. Caring for patients who have experienced a patient safety incident (adverse event) | When Possible |
C9a. Caring for patients at the end of life - Part A: Symptom Management in End of Life | Required |
C9b. Caring for patients at the end of life - Part B: Discussion about transition away from disease modifying treatment | Optional |
For residents in TTP
TTP1a. Managing an inpatient medical service - Part A: Overall Patient Care | Required |
TTP1b. Managing an inpatient medical service - Part B: Interprofessional Care | Required |
TTP3. Assessing and managing patients in whom there is uncertainty in diagnosis and/or treatment | Required |
TTP5. Initiating and facilitating transfers of care through the health care system | Required |
TTP6. Working with other physicians and healthcare providers to develop collaborative patient care plans | Required |
TTP7. Identifying learning needs in clinical practice, and addressing them with a personal learning plan | Required |
TTP8. Identifying and analyzing system-level safety, quality, or resource stewardship concerns in healthcare delivery | Required |
Competencies covered in this activity
1. Practise medicine within their defined scope of practice and expertise | ||||||
1.4. Apply knowledge of the following systems, clinical scenarios, conditions, diseases and therapies applicable to Internal Medicine, including the manifestations, investigation, and management | ||||||
1.4.1. Cardiac | ||||||
1.4.1.1. Symptoms | ||||||
1.4.1.1.1. Chest pain | ||||||
1.4.1.1.2. Dyspnea | ||||||
1.4.1.1.3. Palpitations | ||||||
1.4.1.1.4. Syncope | ||||||
1.4.1.2. Findings and investigations | ||||||
1.4.1.2.1. Abnormal cardiac enzymes | ||||||
1.4.1.2.2. Cardiac murmurs | ||||||
1.4.1.3. Disorders | ||||||
1.4.1.3.1. Acute coronary syndromes and their complications | ||||||
1.4.1.3.2. Cardiomyopathies | ||||||
1.4.1.3.3. Congestive heart failure | ||||||
1.4.1.3.4. Coronary artery disease | ||||||
1.4.1.3.5. Pericarditis, pericardial effusion, and tamponade | ||||||
1.4.1.3.6. Pulmonary hypertension | ||||||
1.4.1.3.7. Valvular heart disease | ||||||
1.4.2. Vascular | ||||||
1.4.2.1. Symptoms | ||||||
1.4.2.1.1. Claudication | ||||||
1.4.2.2. Findings | ||||||
1.4.2.2.1. Peripheral edema | ||||||
1.4.2.3. Disorders | ||||||
1.4.2.3.1. Hypertension | ||||||
1.4.2.3.2. Aortic aneurysm | ||||||
1.4.2.3.3. Peripheral arterial disease | ||||||
1.4.2.3.4. Peripheral venous insufficiency | ||||||
1.4.2.3.5. Venous and arterial ulcers | ||||||
1.4.3. Respiratory | ||||||
1.4.3.1. Symptoms | ||||||
1.4.3.1.1. Acute and chronic dyspnea | ||||||
1.4.3.1.2. Cough | ||||||
1.4.3.1.3. Hemoptysis | ||||||
1.4.3.1.4. Wheeze | ||||||
1.4.3.2. Findings and investigations | ||||||
1.4.3.2.1. Interpretation of pulmonary function testing | ||||||
1.4.3.3. Disorders | ||||||
1.4.3.3.1. Bronchial asthma | ||||||
1.4.3.3.2. Chronic obstructive lung disease | ||||||
1.4.3.3.3. Interstitial lung disease | ||||||
1.4.3.3.4. Pleural effusion | ||||||
1.4.3.3.5. Pneumonia | ||||||
1.4.3.3.6. Pneumothorax | ||||||
1.4.3.3.7. Pulmonary embolism | ||||||
1.4.3.3.8. Sarcoidosis | ||||||
1.4.3.3.9. Lung neoplasms: primary and metastatic, including paraneoplastic syndromes | ||||||
1.4.4. Gastrointestinal and hepatobiliary | ||||||
1.4.4.1. Symptoms | ||||||
1.4.4.1.1. Acute and chronic abdominal pain | ||||||
1.4.4.1.2. Dysphagia | ||||||
1.4.4.1.3. Nausea and vomiting | ||||||
1.4.4.1.4. Regurgitation | ||||||
1.4.4.2. Findings and investigations | ||||||
1.4.4.2.1. Ascites | ||||||
1.4.4.2.2. Encephalopathy | ||||||
1.4.4.2.3. Jaundice | ||||||
1.4.4.2.4. Abnormal liver tests | ||||||
1.4.4.3. Disorders | ||||||
1.4.4.3.1. Acute and chronic constipation | ||||||
1.4.4.3.2. Acute and chronic diarrhea | ||||||
1.4.4.3.3. Bacterial peritonitis | ||||||
1.4.4.3.4. Intestinal obstruction | ||||||
1.4.4.3.5. Malabsorption syndromes | ||||||
1.4.4.3.6. Upper and lower gastrointestinal bleeding | ||||||
1.4.4.3.7. Esophageal | ||||||
1.4.4.3.7.1. Gastroesophageal reflux and its complications | ||||||
1.4.4.3.7.2. Hiatus hernia | ||||||
1.4.4.3.7.3. Motility disorders | ||||||
1.4.4.3.7.4. Varices | ||||||
1.4.4.3.7.5. Neoplasms | ||||||
1.4.4.3.8. Gastroduodenal disease | ||||||
1.4.4.3.8.1. Gastritis | ||||||
1.4.4.3.8.2. Motility disorders | ||||||
1.4.4.3.8.3. Peptic ulcers | ||||||
1.4.4.3.8.4. Neoplasms | ||||||
1.4.4.3.9. Small and large intestine | ||||||
1.4.4.3.9.1. Diseases causing malabsorption, including celiac disease | ||||||
1.4.4.3.9.2. Diverticular disease | ||||||
1.4.4.3.9.3. Infectious diseases | ||||||
1.4.4.3.9.4. Inflammatory bowel disease | ||||||
1.4.4.3.9.5. Irritable bowel syndrome | ||||||
1.4.4.3.9.6. Neoplasms: small intestine and colorectal | ||||||
1.4.4.3.10. Hepatic | ||||||
1.4.4.3.10.1. Acute and chronic hepatitis | ||||||
1.4.4.3.10.2. Cirrhosis and its complications | ||||||
1.4.4.3.10.3. Neoplasms: primary and metastatic | ||||||
1.4.4.3.11. Biliary tract disease | ||||||
1.4.4.3.11.1. Cholelithiasis and its complications | ||||||
1.4.4.3.11.2. Sclerosing cholangitis | ||||||
1.4.4.3.11.3. Neoplasms | ||||||
1.4.4.3.12. Pancreatic disease | ||||||
1.4.4.3.12.1. Acute and chronic pancreatitis | ||||||
1.4.4.3.12.2. Neoplasms | ||||||
1.4.5. Renal | ||||||
1.4.5.1. Findings and investigations | ||||||
1.4.5.1.1. Acid-base disturbances | ||||||
1.4.5.1.2. Fluid and electrolyte abnormalities | ||||||
1.4.5.1.3. Hematuria | ||||||
1.4.5.1.4. Proteinuria | ||||||
1.4.5.2. Disorders | ||||||
1.4.5.2.1. Acute renal failure | ||||||
1.4.5.2.2. Acute tubular necrosis | ||||||
1.4.5.2.3. Chronic kidney disease and its complications | ||||||
1.4.5.2.4. Glomerulonephritis | ||||||
1.4.5.2.5. Interstitial nephritis | ||||||
1.4.5.2.6. Nephritic and nephrotic syndromes | ||||||
1.4.5.2.7. Renal calculi | ||||||
1.4.5.2.8. Renal tubular acidosis | ||||||
1.4.5.2.9. Renovascular hypertension | ||||||
1.4.5.2.10. Renal complications of diabetes, hypertension, and rhabdomyolysis | ||||||
1.4.5.3. Therapies | ||||||
1.4.5.3.1. Renal replacement therapy and transplantation | ||||||
1.4.6. Endocrine and metabolic | ||||||
1.4.6.1. Symptoms | ||||||
1.4.6.1.1. Amenorrhea | ||||||
1.4.6.1.2. Fatigue and malaise | ||||||
1.4.6.1.3. Galactorrhea and gynecomastia | ||||||
1.4.6.1.4. Hirsutism | ||||||
1.4.6.1.5. Loss of libido | ||||||
1.4.6.1.6. Weight gain and loss | ||||||
1.4.6.2. Findings and investigations | ||||||
1.4.6.2.1. Hyper- and hypocalcemia | ||||||
1.4.6.2.2. Hyper- and hypoglycemia | ||||||
1.4.6.2.3. Obesity | ||||||
1.4.6.3. Disorders | ||||||
1.4.6.3.1. Adrenal masses | ||||||
1.4.6.3.2. Diabetes mellitus: type 1 and type 2 | ||||||
1.4.6.3.2.1. Complications of diabetes including retinopathy, neuropathy, vascular disease and ulcers | ||||||
1.4.6.3.3. Hyper – and hypoadrenalism | ||||||
1.4.6.3.4. Hyper – and hypoparathyroidism | ||||||
1.4.6.3.5. Hyper – and hypothyroidism | ||||||
1.4.6.3.6. Lipid disorders | ||||||
1.4.6.3.7. Male hypogonadism | ||||||
1.4.6.3.8. Pancreatic endocrine neoplasms | ||||||
1.4.6.3.9. Pituitary masses | ||||||
1.4.6.3.10. Thyroid enlargement and nodules | ||||||
1.4.7. Neurological | ||||||
1.4.7.1. Symptoms | ||||||
1.4.7.1.1. Acute and chronic headache | ||||||
1.4.7.1.2. Altered mental status and disorders of consciousness | ||||||
1.4.7.1.3. Dizziness and vertigo | ||||||
1.4.7.1.4. Syncope | ||||||
1.4.7.1.5. Tremors | ||||||
1.4.7.1.6. Weakness: local and generalized | ||||||
1.4.7.2. Findings and investigations | ||||||
1.4.7.2.1. Abnormal cranial nerve function | ||||||
1.4.7.2.2. Determination of brain death | ||||||
1.4.7.2.3. Increased intracranial pressure | ||||||
1.4.7.3. Disorders | ||||||
1.4.7.3.1. Acute spinal cord compression | ||||||
1.4.7.3.2. Amyotrophic lateral sclerosis | ||||||
1.4.7.3.3. Cerebral vascular disease: stroke and transient ischemic attack (TIA) | ||||||
1.4.7.3.4. Dementia and delirium | ||||||
1.4.7.3.5. Guillain-Barré syndrome | ||||||
1.4.7.3.6. Meningitis and encephalitis | ||||||
1.4.7.3.7. Movement disorders including Parkinson’s syndrome | ||||||
1.4.7.3.8. Multiple sclerosis | ||||||
1.4.7.3.9. Myasthenia gravis | ||||||
1.4.7.3.10. Peripheral neuropathy | ||||||
1.4.7.3.11. Seizure disorders and status epilepticus | ||||||
1.4.7.3.12. Brain neoplasms | ||||||
1.4.8. Hematologic | ||||||
1.4.8.1. Findings and investigations | ||||||
1.4.8.1.1. Anemia | ||||||
1.4.8.1.2. Eosinophilia | ||||||
1.4.8.1.3. Lymphadenopathy | ||||||
1.4.8.1.4. Splenomegaly | ||||||
1.4.8.2. Disorders | ||||||
1.4.8.2.1. Congenital and acquired bleeding disorders including, but not limited to hemophilia, diffuse intravascular coagulation, and thrombocytopenic purpura | ||||||
1.4.8.2.2. Hemoglobinopathies | ||||||
1.4.8.2.3. Hypercoaguable states | ||||||
1.4.8.2.4. Leukemia | ||||||
1.4.8.2.5. Lymphoma | ||||||
1.4.8.2.6. Multiple myeloma and other dysproteinemias | ||||||
1.4.8.2.7. Myelodysplastic | ||||||
1.4.8.2.8. Myeloproliferative | ||||||
1.4.8.2.9. Porphyria | ||||||
1.4.8.2.10. Thrombophilia | ||||||
1.4.8.2.11. Venous thromboembolic disease | ||||||
1.4.8.3. Therapies | ||||||
1.4.8.3.1. Anticoagulant therapy | ||||||
1.4.8.3.2. Prophylaxis for venous thromboembolic disease | ||||||
1.4.8.3.3. Transfusion of blood products | ||||||
1.4.9. Musculoskeletal | ||||||
1.4.9.1. Symptoms | ||||||
1.4.9.1.1. Back pain | ||||||
1.4.9.1.2. Muscular pain | ||||||
1.4.9.1.3. Proximal muscle weakness | ||||||
1.4.9.2. Disorders | ||||||
1.4.9.2.1. Acute monoarthritis | ||||||
1.4.9.2.2. Acute and chronic polyarthritis | ||||||
1.4.9.2.3. Ankylosing spondylitis | ||||||
1.4.9.2.4. Fibromyalgia | ||||||
1.4.9.2.5. Gout and pseudogout | ||||||
1.4.9.2.6. Osteoarthritis | ||||||
1.4.9.2.7. Osteomyelitis | ||||||
1.4.9.2.8. Paget’s disease of bone | ||||||
1.4.9.2.9. Raynaud’s phenomenon | ||||||
1.4.9.2.10. Rheumatoid arthritis | ||||||
1.4.9.2.11. Scleroderma | ||||||
1.4.9.2.12. Septic arthritis | ||||||
1.4.9.2.13. Sero-negative arthropathies | ||||||
1.4.9.2.14. Sjögren’s syndrome | ||||||
1.4.9.2.15. Systemic lupus erythematosis | ||||||
1.4.9.2.16. Temporal arteritis and polymyalgia rheumatica | ||||||
1.4.9.2.17. Primary and secondary bone and soft tissue neoplasms | ||||||
1.4.10. Immunologic | ||||||
1.4.10.1. Amyloidosis | ||||||
1.4.10.2. Immunoglobulin deficiencies | ||||||
1.4.10.3. Immunosuppression secondary to cancer and immunomodulatory agents | ||||||
1.4.10.4. Opportunistic infections | ||||||
1.4.11. Dermatologic | ||||||
1.4.11.1. Symptoms | ||||||
1.4.11.1.1. Pruritus | ||||||
1.4.11.2. Findings and investigations | ||||||
1.4.11.2.1. Abnormalities of nails | ||||||
1.4.11.2.2. Clubbing | ||||||
1.4.11.2.3. Maculopapular eruptions | ||||||
1.4.11.2.4. Petechiae, purpura, ecchymosis | ||||||
1.4.11.2.5. Pigmented lesions | ||||||
1.4.11.2.6. Urticaria | ||||||
1.4.11.2.7. Vesicular eruptions | ||||||
1.4.11.2.8. Skin and nail manifestations due to systemic disease | ||||||
1.4.11.2.8.1. Celiac disease | ||||||
1.4.11.2.8.2. Connective tissue disease | ||||||
1.4.11.2.8.3. Endocrine and metabolic disease | ||||||
1.4.11.2.8.4. Inflammatory bowel disease | ||||||
1.4.11.2.8.5. Malignancy | ||||||
1.4.11.2.8.6. Nutritional deficiencies | ||||||
1.4.11.2.8.7. Systemic immunosuppression | ||||||
1.4.11.3. Conditions | ||||||
1.4.11.3.1. Bullous skin disease | ||||||
1.4.11.3.2. Eczema | ||||||
1.4.11.3.3. Erythema nodosum | ||||||
1.4.11.3.4. Psoriasis | ||||||
1.4.11.3.5. Stasis dermatitis | ||||||
1.4.11.3.6. Stevens-Johnson syndrome | ||||||
1.4.11.3.7. Toxic epidermal necrolysis | ||||||
1.4.11.3.8. Skin cancer and pre-malignant conditions | ||||||
1.4.12. Infection | ||||||
1.4.12.1. Disorders | ||||||
1.4.12.1.1. Infective endocarditis | ||||||
1.4.12.1.2. Pneumonia | ||||||
1.4.12.1.3. Infectious diarrhea | ||||||
1.4.12.1.4. Clostridium difficile colitis | ||||||
1.4.12.1.5. Intra-abdominal infections | ||||||
1.4.12.1.6. Urosepsis | ||||||
1.4.12.1.7. Meningitis and encephalitis | ||||||
1.4.12.1.8. Bone and joint infections | ||||||
1.4.12.1.9. Cellulitis and other skin infections | ||||||
1.4.12.1.10. Necrotizing soft tissue infections | ||||||
1.4.12.1.11. Fever of unknown origin | ||||||
1.4.12.1.12. Fever in the immuno-compromised host | ||||||
1.4.12.1.13. Fever in the hospitalized patient | ||||||
1.4.12.1.14. Fever, skin diseases, and diarrhea in the returning traveler | ||||||
1.4.12.1.15. Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and its treatment and complications, including but not limited to: | ||||||
1.4.12.1.15.1. Fever | ||||||
1.4.12.1.15.2. Weight loss | ||||||
1.4.12.1.15.3. Dyspnea, cough, hemoptysis | ||||||
1.4.12.1.15.4. Dysphagia, diarrhea | ||||||
1.4.12.1.15.5. Anemia, neutropenia, thrombocytopenia | ||||||
1.4.12.1.15.6. Metabolic derangements | ||||||
1.4.12.1.15.7. Opportunistic infections | ||||||
1.4.12.1.16. Malaria | ||||||
1.4.12.1.17. Sexually transmitted infections | ||||||
1.4.12.1.18. Tuberculosis, including intradermal testing and interpretation | ||||||
1.4.12.2. Therapies | ||||||
1.4.12.2.1. Spectrum of activity, adverse effects, and dose adjustments for antibiotics | ||||||
1.4.12.2.2. Antimicrobial stewardship | ||||||
1.4.12.2.3. Infection control in the hospital setting | ||||||
1.4.12.3. Malignancy | ||||||
1.4.12.3.1. Oncologic emergencies including, but not limited to: | ||||||
1.4.12.3.1.1. Hypercalcemia | ||||||
1.4.12.3.1.2. Spinal cord compression | ||||||
1.4.12.3.1.3. Superior vena cava syndrome | ||||||
1.4.12.3.1.4. Pleural and pericardial effusion | ||||||
1.4.12.3.1.5. Tumour lysis syndrome | ||||||
1.4.12.3.2. Screening and prevention | ||||||
1.4.12.3.3. Complications of chemotherapy including myelosuppression and hyperemesis | ||||||
1.4.12.3.4. Principles of diagnosis and treatment of the following: | ||||||
1.4.12.3.4.1. Breast cancer | ||||||
1.4.12.3.4.2. Ovarian cancer | ||||||
1.4.12.3.4.3. Endometrial and cervical cancer | ||||||
1.4.12.3.4.4. Urothelial cancer | ||||||
1.4.12.3.4.5. Prostate cancer | ||||||
1.4.12.3.4.6. Head and neck cancers | ||||||
1.4.12.3.4.7. Para-neoplastic syndromes | ||||||
1.4.13. Medical aspects of specific situations | ||||||
1.4.13.1. Common medical emergencies | ||||||
1.4.13.1.1. Life-threatening cardiac, respiratory, gastrointestinal, metabolic, neurologic and other organ system dysfunction and abnormalities | ||||||
1.4.13.1.2. Hyperthermia / hypothermia | ||||||
1.4.13.1.3. Shock, including knowledge and identification of the different etiologies | ||||||
1.4.13.1.4. Cardio-respiratory arrest | ||||||
1.4.13.1.5. Poisoning | ||||||
1.4.13.1.6. Severe drug reactions including but not limited to anaphylaxis and toxic epidermal necrolysis | ||||||
1.4.13.1.7. Complications of chemotherapy | ||||||
1.4.13.1.7.1. Febrile neutropenia | ||||||
1.4.13.1.7.2. Tumour lysis syndrome | ||||||
1.4.13.2. Peri-operative assessment and management | ||||||
1.4.13.2.1. Hypertension as well as heart, lung, metabolic, and kidney diseases | ||||||
1.4.13.2.2. Anticoagulants and anti-platelet agents | ||||||
1.4.13.2.3. Prophylaxis for infection | ||||||
1.4.13.2.4. Prophylaxis for venous thromboembolism | ||||||
1.4.13.3. Occupational considerations | ||||||
1.4.13.3.1. Assessment of fitness to work | ||||||
1.4.13.4. Medical aspects of mental illness and addiction | ||||||
1.4.13.4.1. Depression presenting as physical illness | ||||||
1.4.13.4.2. Effects of depression on the course of medical disease | ||||||
1.4.13.4.3. Effects and side effects of psychiatric medications | ||||||
1.4.13.4.4. Substance use, abuse and withdrawal | ||||||
1.4.13.5. Pregnancy | ||||||
1.4.13.5.1. Pregnancy induced change in blood volume, hemodynamics, and cardio-respiratory and renal physiology | ||||||
1.4.13.5.2. Findings and investigations | ||||||
1.4.13.5.2.1. Abnormal liver tests | ||||||
1.4.13.5.2.2. Proteinuria | ||||||
1.4.13.5.3. Pre-existing medical conditions | ||||||
1.4.13.5.3.1. Hypertension | ||||||
1.4.13.5.3.2. Valvular heart disease | ||||||
1.4.13.5.3.3. Asthma | ||||||
1.4.13.5.3.4. Disorders of glucose homeostasis including diabetes mellitus | ||||||
1.4.13.5.3.5. Seizure disorders | ||||||
1.4.13.5.3.6. Venous thromboembolic disease | ||||||
1.4.13.5.3.7. Infectious diseases including HIV and hepatitis | ||||||
1.4.13.5.4. Disorders with onset during pregnancy | ||||||
1.4.13.5.4.1. Hypertensive disorders | ||||||
1.4.13.5.4.2. Cardiomyopathy | ||||||
1.4.13.5.4.3. Liver diseases | ||||||
1.4.13.5.4.4. Seizures | ||||||
1.4.13.5.4.5. Thrombocytopenia | ||||||
1.4.13.5.5. Therapies | ||||||
1.4.13.5.5.1. Endocarditis prophylaxis | ||||||
1.4.13.5.5.2. Drug prescribing in pregnancy and post-partum period | ||||||
1.4.13.6. The elderly | ||||||
1.4.13.6.1. Symptoms | ||||||
1.4.13.6.1.1. Constipation | ||||||
1.4.13.6.1.2. Depression | ||||||
1.4.13.6.1.3. Delirium | ||||||
1.4.13.6.1.4. Falls and immobility | ||||||
1.4.13.6.1.5. Frailty and failure to thrive | ||||||
1.4.13.6.1.6. Gait instability | ||||||
1.4.13.6.1.7. Urinary and fecal incontinence | ||||||
1.4.13.6.2. Disorders | ||||||
1.4.13.6.2.1. Dementia including Alzheimer’s disease, Lewy-body, vascular, and frontal lobe dementias | ||||||
1.4.13.6.2.2. Nutritional deficiencies | ||||||
1.4.13.6.2.3. Neglect/abuse | ||||||
1.4.13.6.3. Therapies | ||||||
1.4.13.6.3.1. Rational drug prescribing | ||||||
1.4.13.7. End of life | ||||||
1.4.13.7.1. Symptoms | ||||||
1.4.13.7.1.1. Constipation | ||||||
1.4.13.7.1.2. Delirium | ||||||
1.4.13.7.1.3. Dyspnea | ||||||
1.4.13.7.1.4. Nausea and vomiting | ||||||
1.4.13.7.1.5. Pain | ||||||
1.4.13.7.2. Disorders | ||||||
1.4.13.7.2.1. Nutritional deficiencies | ||||||
1.4.13.7.3. Therapies | ||||||
1.4.13.7.3.1. Use of opioids and other medications | ||||||
1.4.13.7.3.2. Principles of palliative care and medical aid in dying (MAID) |
Training experiences included in this activity
Core of Discipline
Required1.5. After hours coverage for a broad spectrum of inpatients and internal medicine consultation to the emergency department
1.7. Internal medicine in a community based setting
Transition to Practice
Required1.4. Community based Internal Medicine
Recommended
3.5. Experience in any subspecialty of Internal Medicine. This may be inpatient or ambulatory care