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Vanderbilt Core Clinical Curriculum

Functional Decline

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with FUNCTIONAL DECLINE can include:

Medical Knowledge Learning Topics related to FUNCTIONAL DECLINE

1. Risk Factors for and prevention of functional decline
2. Appropriate screening techniques and intervals for functional decline
3. Quantification of the severity of functional decline/impairment

Diagnostic Evaluation Learning Topics related to FUNCTIONAL DECLINE:

1. Age-appropriate medical history, documentation, and presentation that differentiates among etiologies of disease, including:

  • characterization of a patient’s functional decline:
    • temporal sequence: onset, frequency, duration, progression
    • associated symptoms: nausea, vomiting, fever, chills, anorexia, weight change, dysphagia, dysuria, altered bowel function, loss of balance, gait changes, weakness, numbness, changes in speech, sleep patterns, mood/behavior changes.
    • exacerbating and remitting factors: position, activity, medications
  • pertinent medical history (e.g., prior surgical and medical history, other illness)
  • medications (e.g., prescription and supplements)
  • family history
  • social history and related social support

2. Physical examination to establish the diagnosis and severity of disease, including:

  • correct order and technique for performing a screening physical examination
  • neurologic examination, including mental status examination
  • psychiatric assessment, including mood

3. Differential diagnosis generation including the most important and likely causes of a patient’s functional decline, recognizing specific history and physical exam findings that distinguish between potential causes, including normal aging
4. Diagnostic and laboratory testing necessary to determine the cause of a patient’s functional decline, including indication, interpretation both prior to and after initiating treatment based on the differential diagnosis, and in the context of test performance, cost, and patient preferences. Examples may include:

  • Head CT/brain MRI
  • Imaging of vessels of head and neck (e.g., carotid ultrasound, CTA, MRA, angiography)
  • Lumbar puncture with measurement of opening pressure
  • Neuropsychiatric testing
  • Electroencephalogram (EEG)
  • Laboratory screening, including TSH, B12, RPR

5. Communication to patients and families about the working diagnosis, differential diagnosis, and current plan, in a caring and compassionate manner

Management Plan Learning Topics related to FUNCTIONAL DECLINE:

1. Determination of the urgency of treatment for various causes of functional decline
2. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle
3. Psychological support referral for patient and caregivers, if indicated
4. Follow-up planning, including awareness of resources and limitations to support caregivers and patients

Potential Differential Diagnosis Topics Include:

Urinary Incontinence

  • Urge Incontinence
  • Stress Incontinence
  • Bladder Outlet Obstruction
  • Detrusor underactivity

Dementia

  • Alzheimer’s type dementia
  • Vascular dementia
  • Lewy body dementia
  • Frontotemporal dementia
  • Normal pressure hydrocephalus
  • Trauma

Delirium

  • Agitated delirium
  • Hypoactive delirium

Depression and other Mood Disorders

  • Depression
  • Hyperthyroidism
  • Hypothyroidism
  • Adjustment disorder

Musculoskeletal injury, arthritis, and osteoporosis

  • Back pain
    • Sciatica
    • Compression fracture/vertebral body disease
    • Cauda equina
    • Muscular injury/strain
  • Hip/Knee/Shoulder pain/injury
  • Fall prevention, evaluation and treatment
  • Fragility fracture

Stroke

  • Cardioembolic
  • Large-artery disease
  • Small-vessel disease
  • Anterior circulation
  • Posterior circulation

Other neurodegenerative diseases

  • Amyotrophic lateral sclerosis
  • Parkinson’s disease
  • Huntington’s disease
  • Alcohol use disorder

Pharmacotherapy

  • Polypharmacy
  • Age-associated changes in pharmacodynamics, metabolism, and body composition
  • Adverse drug events, commonly associated with cardiovascular drugs, diuretics, nonsteroidal anti-inflammatory drugs, hypoglycemic, atypical antipsychotic medications, and anticoagulants