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Pediatrics

Objectives Readings/Assignments Policies Clerkship Sites Evaluations/Assessments
Curriculum Didactics Preceptor Handouts Sample Documentation

Pediatrics - Handbook (PDF)


 

Objectives:

The objective of the Pediatric Clerkship is to facilitate the student’s attainment of the Core Pediatric (CP) and Universal (U) competencies as outlined in the Curriculum.

Knowledge and Lifelong Learning
By the conclusion of the Pediatric Clerkship, students will demonstrate:

  • Acquisition of basic knowledge of growth and development (physical, physiologic and psychosocial) and of its clinical application from birth through adolescence
  • Acquisition of the knowledge necessary for the diagnosis and initial management of common acute and chronic illnesses
  • Development of clinical problem-solving skills
  • Knowledge of the ethical, social, economic, and cultural influences upon the health of and health care delivery to diverse patients and patient populations
  • Understanding of the influence of family, community, and society on the child in health and disease and how to respond to these factors by through appropriate course of action at both the individual and the community level
  • Recognition of effective strategies for health promotion as well as disease and injury prevention
  • Ability to access a broad range of resources in support of evidence-based decisionmaking for the evaluation and treatment of clinical conditions

Interpersonal and Communication
By the conclusion of the Pediatric Clerkship, students will demonstrate:

  • Development of communication skills that facilitate clinical interaction with children, adolescents, and their families to ensure complete, accurate data are obtained
    - Establish a professional relationship with a patient
    - Display sensitivity and responsiveness to patient’s and parents’ culture, ethnicity, gender and disabilities
    - Build a comprehensive medical and social/personal history
  • Competency in the physical examination of infants, children, and adolescents
    - Conduct a focused or comprehensive physical examination as indicated
    - Utilize an approach suitable for the patient’s developmental and cognitive level
    - Construct a differential diagnosis, and recommend a course of treatment consistent with current standards of care
  • Ability to communicate (written & oral) clearly, professionally, and effectively with patients, their family members, health care team members, and peers
  • Ability to listen and respond appropriately to constructive feedback from peers and teachers, as well as give constructive feedback and evaluation to peers and faculty as requested
  • An understanding of the approach of pediatricians to the healthcare of children and adolescents through interactions with community financial, political, and legal resources

Professionalism
By the conclusion of the Pediatric Clerkship, students will demonstrate:

  • Development of the attitudes and professional behaviors appropriate for clinical practice
    - Identify personal strengths and weaknesses in the care of patients and working with colleagues and allied health professionals
    - Sensitivity to differences in cultural, ethnic, educational, socioeconomic, and sexual orientation backgrounds and the ability to respond appropriately within these contexts
    - Demonstrate the ability to make changes in their own behavior that facilitate collaborative relationships
  • Demonstrate a pattern of responsible behaviors consistent with the highest ethical standards of the profession: honesty, confidentiality, reliability, dependability, civility, and punctuality
  • Demonstrate a commitment to leadership and the advancement of new knowledge

 

Readings/Assignments:

 

From

Reading Name

File Download

Elizabeth Jane Elliott

Acute gastroenteritis in children

PDF

James P. Keating, MD

Chronic Diarrhea

PDF

 

Hyperbilirubinemia in the Term Newborn

PDF

Thomas S. Renshaw, MD

Child who has a limp

PDF

Penelope H. Dennehy, MD

Acute Diarrheal Disease in Children:
Epidemiology, Prevention, andTreatment

PDF

Kathleen Gutierrez, MD

Bone and Joint Infections in Children

PDF

Alice L. Pong, MD,
John S. Bradley, MD

Guidelines for the Selection of Antibacterial
Therapy in Children

PDF

Sheldon L. Kaplan, MD

Osteomyelitis in Children

PDF


 

Policies:

Site Logistics (Safety, Parking, Lockers, and Pagers)

The following items are provided for your use during the Clerkship, and must be returned at the conclusion of the Clerkship:

  • Medical Student ID Badge / Swipe Card

This badge should be worn at all times when you are inside the hospital.

- It is also a swipe card which provides access to the hospital, resident facilities, and employee parking lot.

- Gates to the Employee Parking will be open from 6:00 – 8:00 am and 2:30 – 3:30 pm. Access will be restricted at all other times and will only be accessible using the ID Badge.

  • Nelson Essentials of Pediatrics

The following items are provided for use during the Inpatient rotation, and must be returned at the conclusion of your inpatient month:

Pager for use within the hospital

Meal Card which can be used in the cafeteria and grill

A locker will be assigned to you. Student lockers are located just outside the Resident’s Lounge. The lounge and call rooms are accessible using your ID badge.

A pair of scrubs will be issued for use during your on-call nights. At the conclusion of your inpatient month, the scrubs should be placed in the hamper located in the Medical Education department.

Failure to return any of the items listed above will result in your grade being withheld.

Hospital security may be reached at any time through the operator (dial 0). If at any time during your clerkship you find yourself in a situation where your safety has been compromised, please notify me immediately.

Absence Policy

Absences will be managed according to the WSU Boonshoft SOM Student Policy Guide, Absences, Year-3 Clerkships. It is available @ http://www.med.wright.edu/students/guide/grades.html#year3 and has been reproduced below for your reference.

Absences from a scheduled clerkship activity due to personal illness or a family crisis will be handled individually by your clerkship director or his/her designee. You are responsible for notifying your preceptor and the specific clerkship office immediately of your reason for absence. If the absence exceeds two days, you must (a) submit a statement from your physician and (b) speak directly to the clerkship director (or designee) to arrange to make up the lost time.

Absences for any other reason (e.g., a conference or to attend a family function) will be considered unexcused, unless written approval is received from the clerkship director at least 30 days prior to the event causing the absence. In any case, you must make up all time lost. An unexcused absence will be reflected unfavorably on your written record and may adversely affect your clerkship grade. Until the time missed is made up, your grade will be recorded as an Incomplete.

For official holidays, follow the holiday schedule of the hospital, clinic, or practitioner's office to which you are assigned unless specifically instructed otherwise by the clerkship director.

 

Didactic Schedule

All students are required to attend didactics on Wednesday mornings and Friday afternoons throughout the Clerkship.

  Mon Tue Wed Thu Fri

AM

 

 

Grand Rounds Didactics

 

 

PM

 

 

 

 

Didactics

The clinical problems, lecture prework, and other related information is available on the Educational Objectives page

Access to documents in selected areas within the Website require your Campus (“w”) Login and password.

It is your responsibility to ensure all required prework is completed prior to the lectures.

You are welcome to attend other educational conferences offered at Dayton Children’s, as long as they don’t conflict with your assigned Clerkship activities.

Clinical Problems

The ability to solve problems is the essence of clinical medicine. The Pediatric Clerkship curriculum includes Clinical Problems. A complete pediatrics curriculum is beyond the scope of an eight-week clerkship. However, common and important pediatric problems have been emphasized, which if mastered should provide you with a solid understanding of general pediatrics.

You are responsible for participating during group discussions and solving these problems throughout the course of the Clerkship. The Clinical Problems should be reviewed in advance so when you encounter them, their solutions will be more meaningful. The syllabus contains a specific curriculum to guide your reading and areas with which you should become familiar. To determine the proper solution you will also need to gather information from multiple sources. These sources may include textbooks, journals, online information, seminars, or discussions with our faculty, residents, or other students.

Documentation of Clinical Encounters

The Department of Pediatrics has developed a listing of clinical conditions students should be exposed to during the clerkship. Your encounter with either patients or presentations dealing with the specific condition or diagnosis must be documented on the Clinical Encounter Form. The clinical encounter form will be collected on the final day of the clerkship and remain a part of your educational file.

Clinical Responsibilities

Your primary responsibility is patient care. Clinical duties will vary depending upon rotation and site. At the beginning of each month you should clarify with your attendings and residents what specifically is expected of you. Please note the WSU BSOM Protocol for Faculty Supervisors is sent to our voluntary faculty each August.

In the clinical setting you will be in contact with infectious agents. Good hand washing / hand disinfection before and after each patient contact is the best protection for you and your patients. Students are required to follow the infection control precautions established by DCMC.

At least once during the month the intern, senior resident, or attending, should observe the student performing a history and physical examination.

Please note our department policy entitled, "Expectations for WSU BSOM Year III Students for the Inpatient Month of the Pediatric Clerkship," which is included in this syllabus, is provided to attendings and residents who interact with clerkship students.

Recommended Texts

A specific textbook is not required for the clerkship. We do provide a copy of Nelson Essentials of Pediatrics for your use during the clerkship. The following is a list of several other references, which may be helpful.

Nelson Essentials of Pediatrics, Behrman, Saunders

Rudolph's Pediatrics, Rudolph, McGraw Hill

Primary Pediatric Care, Hoekelman, Mosby

Oski’s Pediatrics: Principles and Practice, McMillan, Lippincott

Nelson Essentials of Pediatrics, Kliegman, Marcdante, Jenson, Behrman

Rudolph's Fundamentals of Pediatrics, Rudolph & Kamei, Appleton and Lange

Signs and Symptoms in Pediatrics,Tunnessen, Lippincott, Williams & Wilkins

Saunders Manual of Pediatric Practice, Finberg, Saunders


 

Clerkship Sites:

Clerkship Director
Gregory Toussaint, MD
gregory.toussaint@wright.edu
(937) 641-3453 Phone
(937) 641-5931 Fax

Clerkship Administrator
Rebecca Elofskey
ElofskeyR@childrensdayton.org
(937) 641-3453 Phone
(937) 641-5931 Fax

The Children's Medical Center of Dayton
One Children's Plaza
Dayton, OH 45404-1815

Wright Patterson Air Force Base
4881 Sugar Maple Drive, Bldg 830
WPAFB, OH 45433

Various Community Preceptors


 

Evaluations/Assessments:

Evaluations of the Student

File Download

PED Mid-Term Feedback Form

PDF


 

NBME Pediatric Shelf Examination: The final examination is given the last day of the clerkship. If special testing accommodations are needed (e.g., for a disability), you must inform the Clerkship Director during the first week of the clerkship so arrangements may be made.

Similar to other MSIII Clerkships the passing grade is determined by the national 5th percentile for the Pediatric Subject Examination as reported by the National Board of Medical Examiners (NBME).

 

Grading Composite: Your final clerkship grade is based on the following three components:

Component

% of Grade

Evaluator

Inpatient Clinical Performance Evaluation

35%

Attendings Sr. Residents

Outpatient Clinical Performance Evaluation

35%

Preceptor

Final Exam

30%

NBME Shelf Exam

 

The minimum passing total score for the Clerkship is 70%, with no individual component receiving a score of less than 66%.

  • If you receive a failing grade for any component of the clerkship, the overall grade will be submitted as Incomplete (I).
  • If you fail the Final Exam, you will be permitted one retake of the NBME subject exam. The retake will be scheduled within the following parameters:

Exam must be taken within 90 days of initial notification.

30 days lead time is required to order the exam and make the necessary arrangements

The retake must be scheduled for a date when a Clerkship exam is already being administered at WSU.

  • If the area of deficiency relates to clinical skills, arrangements will be made for a pediatric history and physical examination to be observed, written up and presented.
  • If this remediation is passed, your final grade will be calculated by utilizing the minimum passing score of 66% for the remediate portion of the grade.
  • If the remediation is failed, or if the inpatient or outpatient rotation is failed due to nonacademic/attitudinal deficiencies, then you will receive a failing grade for the clerkship.

 

Final Evaluation: Approximately 6 weeks after completion of the Clerkship, each student receives a Final Evaluation, via RMS, which contains a summary of their grade, by component, as well as a composite of the evaluation comments. The Final Evaluation is maintained in the office of Student Affairs and is excerpted into the Dean’s letter. A copy of all evaluations and the detailed grading reports are available in the student’s file, which is maintained by the office of the Clerkship Director. This information is available for review by the student upon request.

Appeal of a Course Grade and/or Written Evaluation: Appeal of a grade or narrative assessment will follow the process outlined in the WSU BSOM Student Policy Guide and excerpted below:

  • Appeal to the Course/Clerkship Director
    The first level of appeal of a course grade and/or written evaluation is to the course/clerkship or elective director. The appeal must be submitted and received within 60 days of the grade distribution. If the course/clerkship director determines that there is reason to change the grade or written evaluation, he/she will inform the Office of Student Affairs of the change. If the course/clerkship director does not believe there is sufficient reason to change the grade/written evaluation, he/she will inform the student in writing that the grade/written evaluation stands.
  • Final Appeal of a Course Grade and/or Written Evaluation
    In Biennium 2, a student may appeal the decision of a clerkship director to the department chair. The student is given seven business days from receipt of the course/clerkship director's letter to submit a written notification of intent to appeal. The associate dean/department chair may hear the appeal or appoint an ad hoc faculty committee to act in his/her place.
     
    After reviewing all relevant documents, and the student's testimony and petition, the associate dean/chair will notify the student of his/her decision. The decision is final.

Grounds for appeal include: mathematical or clerical errors; arbitrariness, including discrimination based on race, gender, religion, age, physical handicap, sexual orientation, national origin; and personal malice.


 

Curriculum:

PROFESSIONAL CONDUCT AND ATTITUDES

Rationale

 

Prerequisites


Well-developed data gathering skills, knowledge of ethical principles, and a basic understanding of health law issues are essential foundations for the student. Students should have completed an introductory course on medical ethics providing a basic understanding of ethical principles (autonomy, beneficence, nonmaleficence, and justice) and their application in clinical medicine

Competencies

A. Humanism and Professionalism in Patient and Family Encounters:

Knowledge

  1. Describe and demonstrate behaviors that respect the patient's modesty, privacy, and confidentiality. (U)

  2. Describe the practical applications of the major ethical principles (i.e. justice, beneficence, non-malfeasance and respect for autonomy) (U)

Skills

  1. Demonstrate communication skills with patients and families that convey respect, integrity, flexibility, sensitivity, and compassion. (U)

  2. Demonstrate respect for patient, parent, and family attitudes, behaviors and lifestyles, paying particular attention to cultural, ethnic, and socioeconomic influences to include actively seeking to elicit and incorporate the patient's, parent's and family's attitudes into the health care plan. (U)

  3. Demonstrate behaviors and attitudes that promote the best interest of patients and families, including showing flexibility to meet the needs of the patient and family. (U)

B. Professionalism with Members of the Health Care Team
 
Knowledge

  1. Describe the characteristics of the impaired physician and reflect on your responsibilities to identify and report concerning behavior (M)

Skills

  1. Demonstrate a positive attitude and regard for education by demonstrating intellectual curiosity, initiative, honesty, responsibility, dedication to being prepared, maturity in soliciting, accepting, and acting on feedback, flexibility when differences of opinion arise, and reliability (including completing all assignments with honesty). (U)

  2. Identify and explore personal strengths, weaknesses, and goals – in general and within specific patient encounters. (U)

  3. Describe the impact of stress, fatigue, and personality differences on learning and performance. (U)

 

  1. Demonstrate collegiality and respect for all members of the health care team. (U)

C. Professionalism in the Learner Role
 
Knowledge

  1. Describe a pediatrician's role and responsibility in advocating for the needs of patients (individual and populations) within society. (M)

Skills

  1. Demonstrate behaviors that enhance the experience of the entire group of learners. (M)

 

SKILLS

Rationale
An essential skill for success as a clinician and lifelong learner is clinical problem solving. The process of going from a patient's chief complaint to the creation of an appropriate differential diagnosis and the formulation of a diagnostic therapeutic plan is the core of clinical medicine. Skills essential for competent medical care include the ability to conduct an interview, perform a physical examination, manage medical data, communicate written and oral information, integrate basic science knowledge, search and read the literature critically, and teach. The care of individual patients requires the application of all of these skills.


Prerequisites

  • Introductory course in physical diagnosis which includes general physical examination techniques and the use of diagnostic instruments.

  • Basic competency in patient interviewing to include an understanding of different styles of questions used in the medical review, such as open-ended, directed, follow-up, and summary questions.

  • Awareness of the affects of personal and cultural differences in the provision of care.

General Competencies (all skills are CP unless specifically designated U or M)

  1. Demonstrate sensitivity to confidentiality, privacy, and modesty, during the medical interview and physical examination (U) (see professionalism)

  2. Demonstrate an ability to perform an age-appropriate history and physical examination in children of all ages (CP)

Specific Skills:


A. Interviewing Skills

  1. Demonstrate an ability to obtain the following information in an age-appropriate and sensitive manner from a child and or the accompanying adult: (CP)

Past History

    • Neonatal history, including:

    • Birth weight and approximate gestational age

    • Maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications

    • Problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections

    • Immunizations

    • Previous hospitalizations (U)

    • Surgeries (U)

    • Medications and medication allergies (U)

    • Chronic medical conditions (U)

    • Growth and development

    • Nutrition (U)

Family History:

    • Age and health of family members to include acute and chronic medical conditions (U)

    • Drug and alcohol abuse (U)

    • Construct a family pedigree

Social History:

  • Household composition and socioeconomic status (U)

  • School, caregiver, and peer relationships (U)

  • HEADSS assessment

  • Environmental and Personal Safety Assessment:

  • Seat belts and car seats

  • Bicycle helmets

  • Firearms in the home

  • Smoking (U)

  • Lead exposure

  • Home safety for infants and toddlers

B. Physical Examination Skills

  1. Demonstrate the role of patient observation in determining the nature of a child's illness and developmental stage (CP)

  2. Conduct a pediatric physical examination appropriate to the nature of the visit or complaint (complete vs. focused) (U) and the age of the patient (CP)

  3. Demonstrate an ability to perform the following examination skills (CP)

Appearance

  • Interpret the general appearance of the child, including size, morphologic features, development, behaviors and interaction of the child with the parent and examiner.

  • Identify signs of acute and chronic illness in a neonate, infant, toddler, school aged child, and adolescents as evidenced by skin color, respiration, hydration, mental status, cry and social interaction.

Vital signs

  • Measure vital signs, demonstrating knowledge of the appropriate blood pressure cuff size and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic)

  • Identify variations in vital signs based on age of the patient, the presence or absence of disease, and testing modalities (e.g. blood pressure cuff size).

Growth (See section on Growth)

  • Accurately graph and interpret height (length), weight, and head circumference

  • Calculate, plot, and interpret BMI (U)

  • Describe the usefulness of longitudinal data in assessing growth

Development (See section on Development)

  • Accurately identify and interpret major developmental milestones of the neonate, infant, toddler, school-aged child, and adolescent.

Heent

  • Observe, measure, and describe head size and shape, symmetry, facial features, and ear position as part of the examination for dysmorphic features

  • Identify sutures and fontanels in neonates and interpret the findings.

  • Identify the red reflex and discuss how it is used to detect corneal opacities and intraocular masses.

  • Detect the corneal light reflection and discuss how it is used to identify strabismus

  • Assess hydration of the mucous membranes.

  • Assess dentition (U)

  • Observe the tympanic membrane using an otoscope and an insufflator

  • Identify the structures of the oropharynx (e.g. uvula, tonsils, palate, tongue) and recognize signs of pathology (U)

Neck

  • Palpate lymph nodes and describe what anatomic areas they drain (U)

  • Demonstrate maneuvers that test for nuchal rigidity

  • Palpate the thyroid and any neck masses (U)

Chest

  • Observe, measure and interpret the rate, pattern and effort of breathing (U)

  • Identify normal variations of respiration and signs of respiratory distress e.g. grunting, flaring, and retraction (U)

  • Identify normal breath sounds and findings consistent with respiratory pathology such as stridor, wheezing, crackles and asymmetric breath sounds (U)

  • Identify transmitted upper airway sounds (U)

  • Observe and describe breast tissue according to developmental stage (e.g. Tanner scale) (CP) and palpate breast tissue (M)

Cardiovascular

  • Identify the pulses in the upper and lower extremities through palpation.

  • Observe and palpate precordial activity (U).

  • Describe cardiac rhythm, rate, and quality (such as intensity, pitch, and location) of the heart sounds and murmurs and variation with maneuvers through auscultation. (U)

  • Assess peripheral perfusion, using a test for capillary refill. (U)

  • Identify central versus peripheral cyanosis

Abdomen

  • Palpate the liver, spleen and kidneys, and interpret the finding based on the age of the patient.

  • Assess the abdomen for distention, tenderness, and masses through observation, auscultation, and palpation (U)

  • Determine the need for a rectal examination, (CP) and demonstrate the age-appropriate technique (M).

Genitalia

  • Describe the difference in appearance of male and female genitalia at different ages and developmental (e.g. Tanner) stages.

  • Palpate the testes (CP) and identify genital abnormalities in males, including cryptorchidism (CP), hypospadias, phimosis, hernia, hydrocele and testicular mass (M).

  • Recognize genital abnormalities in females including signs of virilization (CP) imperforate hymen, labial adhesions and signs of injury.(M)

Extremities

  • Examine the hips of a newborn for developmental dysplasia of the hip using the Ortolani and Barlow maneuvers

  • Observe and describe the gait of children at different ages.

  • Identify age-related variations in the examination of the extremities, such as tibial torsion, genu valgus, flat feet, etc. (M)

  • Recognize pathology, such as joint effusions, signs of trauma, and inflammation(CP) and restricted or excessive joint mobility (M)

Back

  • Perform and interpret a screening test for scoliosis.

  • Examine the back for midline tufts of hair, pits, sacral dimples, or masses

Neurologic examination

  • Elicit the primitive reflexes that are present at birth and describe how they change as the child develops.

  • Assess the quality and symmetry of tone, strength and reflexes, using age-appropriate techniques. (M)

  • Assess the major developmental milestones of newborns, infants, toddlers, school aged, children, and adolescents.

Skin

  • Describe and assess turgor, perfusion, color, hypo and hyperpigmented lesions, and rashes through observation and palpation (U)

  • Identify jaundice, petechiae, purpura, bruising, vesicles, and urticaria. (U)

C. Patient Communication Skills

  1. Conduct an effective interview by adapting the interview to the visit (e.g., first visit, acute care, health supervision), or chief complaint, (U)

  2. Demonstrate effective verbal and non-verbal communications skills with children and their parents or families that include

    • Establishment of rapport taking into account the patient's age and development stage (CP)

    • Use of communication techniques that enable development of a therapeutic alliance being sensitive to the unique social condition and cultural background of the family (U)

    • Identification of the primary concerns of the patient and/or family (U).

    • Discussion of medical information in terms understandable to patients and families avoidance of medical jargon (U)

  3. Correctly identify the need for an interpreter in specific patient-physician interactions. (U)

  4. Effectively communicate information about the diagnosis, diagnostic plan, and treatment to the patient and family and assess the patient and families understanding (M).

  5. Describe the important role of patient education in treatment of acute and chronic illness, and prevention of disease. (M)

  6. Observe and reflect on the communication of "bad news" to parents, children and adolescents. (M)

D. Peer Communication Skills

  1. Demonstrate effective oral and written communication with the health care team avoiding jargon and vague terms (e.g. clear and normal). (U).

  2. Present a complete, well-organized verbal summary of the patient's history and physical examination findings, including an assessment and plan modifying the presentation to fit the time constraints and educational goals of the situation. U

  3. Document the history, physical examination, and assessment and plan using a format appropriate to the clinical situation (e.g., inpatient admission, progress note, office or clinic visit, acute illness, health supervision visit, and interval care visits). (U)

  4. Write admission and daily orders for a hospitalized patient (U)

  5. Write a prescription (see Therapeutics section) (U) specific for a child's weight (CP)

E. Problem solving skills

  1. Demonstrate an ability to generate an age-appropriate differential diagnosis and problem list based on the interview and physical examination. (CP)

  2. Outline a diagnostic plan based on the differential diagnosis, and justify the diagnostic tests and procedures taking into account the test's sensitivity, specificity, and predictive value, as well as its invasiveness, risks, benefits, limitations, and costs. (MU)

  3. Interpret the results of diagnostic tests or procedures, recognizing the age-appropriate values for commonly used laboratory tests, such as the CBC, urinalysis, and serum electrolytes. (M)

  4. Formulate a therapeutic plan appropriate to the working diagnosis (MU)

  5. Formulate an educational plan to inform the health care team and family of your thought process and decisions. (MU)

  6. Search for relevant information using electronic (or other) data bases and critically appraise the information obtained to make evidence based decisions. (U)

HEALTH SUPERVISION

Rationale

Health supervision which includes assessment of growth and development, prevention of disease by immunization, prevention of injury by education, screening for treatable conditions and promotion of a healthy environment and a healthy lifestyle is essential to pediatric practice and primary care.

Prerequisites

  • Introductory data gathering skills.

  • Knowledge of metabolic processes in the body including the respective roles of dietary fats, carbohydrates, and protein, and the need for vitamins and minerals

  • Knowledge of normal immune responses, mechanisms of immunization, and modes of transmission of communicable diseases.

  • Knowledge of clinical epidemiologic concepts and the appropriate uses of screening in clinical medicine and the characteristics of a good screening test (i.e. sensitivity, specificity, positive and negative predictive values).

Competencies

Knowledge

  1. List the most common preventable morbidities in childhood and describe strategies for prevention. (CP)

  2. Describe the components of a health supervision visit including health promotion and disease and injury prevention, the appropriate use of screening tools, and immunizations for newborns, infants, toddlers, school aged children, and adolescents. (CP)

  3. Describe the rationale for childhood immunizations. (See Prevention). (CP)

  4. Discuss the rational for screening tests (such as environmental lead questionnaire, domestic violence screening, CBC, urinalysis, blood lead level, and PPD). (CP)

  5. Describe the indications (CP), appropriate use (CP), interpretation (M), and limitations (M) of the following screening tests:

    • Neonatal screening

    • Developmental screening

    • Hearing and vision screening

    • Lead screening

    • Anemia screening

    • Tuberculosis testing

  6. Define anticipatory guidance and describe how it changes based on the age of the child. (CP)

Skills.

  1. Demonstrate an ability to provide age-appropriate anticipatory guidance about nutrition (CP), behavior (CP), immunizations (CP), injury prevention (CP), pubertal development (CP), sexuality (M), and substance use and abuse (M

Processes

All students should see during the course of the Pediatric Clerkship should see an infant, toddler, school aged, and adolescent child for a health care supervision visit.

GROWTH

Rationale

Growth is a defining feature of childhood. Genetic and environmental factors influence the rate of growth and the final stature and body habitus the child attains. Regular monitoring of growth provides the clinician with one of the best indicators of the underlying health of the child.

Prerequisites

Knowledge of the genetic, endocrine, nutritional, and psychosocial influences on growth.

Competencies

Knowledge

  1. Describe variants of normal growth in healthy children, (e.g. familial short stature and constitutional delay). (CP)

  2. Identify and describe abnormal growth patterns based on the family growth history and the child's previous growth e.g. microcephaly, macrocephaly, short stature, obesity, growth abnormalities related to specific physical findings. (CP)

  3. Identify failure to thrive and overweight/obesity in a child or adolescent using BMI and other growth measures and outline the differential diagnosis and initial evaluation. (CP)

Skills

  1. Demonstrate ability to measure and assess growth including height/length, weight, and head circumference and body mass index in patient encounters using standard growth charts. (CP)

Processes

All students on the Pediatric Clerkship should see a patient with real or possible (e. g. parental concern) issues related to growth (e.g. failure to thrive, obesity, short stature, macrocephaly, microcephaly, constitutional delay, small for gestation age). This can be in the context of a well child examination or a child with a known disorder.

 

DEVELOPMENT

Rationale
The physical maturation and intellectual, social and motor development of the child follow predictable patterns, and provide the physician with a good indicator of the child's health and neurological function. The clinician must be familiar with normal patterns of development in order to detect deviations that might be the first sign of a medical or psychosocial problem.

Prerequisites
Preclinical coursework in the scientific underpinning of neurology and neurobiologic development.

Competencies
Knowledge

  1. Describe the four developmental domains of childhood as defined by the Denver Developmental exam (e.g. gross motor, fine motor, language, and social development. (CP)

  2. Describe how abnormal findings on the development screening tools would suggest a diagnosis of developmental delay (CP), autism (M), pervasive developmental delay (M), and mental retardation. (M)

  3. Describe the initial evaluation and need to refer a patient with evidence of developmental delay or abnormality. (M)

Skills

  1. Demonstrate an ability to assess psychosocial, language, physical maturation, and motor development in pediatric patients using appropriate resources (e.g. Bright Futures, the Denver Developmental Standard Test 2, and HEADSS. (CP) Key features might include the following:

    • Newborn/Infant –Disappearance of primitive reflexes; changes in tone and posture; cephalocaudal progression of motor milestones during the first year; stranger anxiety.

    • Toddler/child - Separation and autonomy in two to three-year olds; sequence of language development; concept of school readiness

    • Adolescent - Sequence of physical maturation (e.g. Tanner scales), cognitive development, and assessment of psychosocial and emotional development (e.g. HEADSS).

Processes

All students on the Pediatric Clerkship should see a patient with real or possible (e.g. parental concerns) issues related to development (e.g. delayed or possibly delayed language, motor, fine motor, or social adaptive skills)

 

BEHAVIOR

Rationale
Providing anticipatory guidance especially in the areas of normative or expected behaviors and identification of abnormal behavior is critical to pediatric practice. Knowledge of age-appropriate behavior allows the physician to recognize deviant behaviors and facilitates earlier intervention.

Prerequisites

  • Recognition that the developmental tasks of infancy, childhood and adolescence differ.

  • Knowledge of the genetic and environmental influences on behavior and behavioral patterns.

Competencies
Knowledge

 

 

  1. Identify normal pattern of behaviors in the developing child such as (CP):

    • newborn infants: development and evolution of social skills

    • toddler: autonomy

    • school age: independence

    • adolescence: abstract thinking

  2. Describe the typical presentation of common behavioral problems and issues in different age groups such as: (CP)

    • Newborn/infants: sleep problems, colic

    • toddler: temper tantrums, toilet training, feeding problems

    • school age: enuresis, attention deficit, encopresis (M), autism (M)

    • adolescence: eating disorders (CP), risk-taking behavior (CP), conduct disorders (M)

  3. Describe the emotional disturbances or medical conditions that may manifest as alterations in school performance and peer or family relationships. (CP)

  4. Distinguish between age-appropriate behavior, inappropriate or abnormal behavior, and those that suggest severe psychiatric or development illness in children of different ages (for example head banging, threatening gestures, suicidal) (M)

  5. Describe how somatic complaints may represent psychosocial problems (e.g. recurrent abdominal pain, headache, fatigue, and neurologic complaints (U)

  6. Describe the types of situations where pathology in the family (e.g. alcoholism, domestic violence, depression) contributes to childhood behavior problems (U)

Skills

  1. Identify behavioral and psychosocial problems of childhood using the medical history and physical examination. (CP)

  2. Counsel parents and children about the management of common behavioral concerns such as discipline, toilet training, and eating disorders. (M)

Processes
All students on the Pediatric Clerkship should see a patient or patients with an individual or parental concern over a specified behavior or group of behaviors (e.g. sleep problems, colic, temper tantrums, toilet training, feeding problems, enuresis, attention deficit, encopresis, autism, eating disorders, conduct disorders, head banging, poor school performance).

NUTRITION

Rationale
Proper nutrition promotes growth and helps maintain health. Some degree of assessment of nutrition is a component of almost every pediatric medical visit. In patients presenting with abnormal growth, nutritional assessment is central to diagnosis and treatment.

Prerequisites

  • The appropriate balance of food groups (e.g., the food pyramid of the United States Department of Agriculture/Department of Health and Human Services).

  • Basic science course work on body metabolism, the respective roles of dietary fats, carbohydrates, and protein, and the need for vitamins and minerals.

  • The role of nutrition in preventive health (e.g., the National Cholesterol Education Program guidelines for adults).

Competencies
Knowledge

  1. Describe the advantages of breastfeeding and describe common difficulties experienced by breastfeeding mothers. (CP)

  2. Describe the signs and symptoms of common nutritional deficiencies in infants and children (e.g. iron, vitamin D, fluoride, and inappropriate caloric volume) and how to prevent them. (CP)

  3. Identify children with specific or special nutritional needs (e.g. patients with chronic illness, prematurity, abnormal growth patterns, failure to thrive, obesity, or when family risk factors suggest the possibility that nutritional modification will be needed). (CP)

  4. Describe nutritional factors that contribute to the development of childhood obesity and to failure to thrive. (CP)

  5. Discuss risk factors for the development of cardiac disease and diabetes with families. (U)

Describe the endocrine, cardiovascular, and orthopedic consequences of childhood obesity. (M)

Skills

  1. Obtain a dietary history in children of different ages that includes the following: (CP):

    • Infants: type, amount and frequency of breast or formula feeding, solid foods, and dietary supplements (vitamins, iron, fluoride).

    • Toddler/school age child: milk, juice, soda, fast foods, and meal patterns

    • Adolescents: meal patterns, nutritional supplements, milk, juice, soda, alcohol, snacking, and fad diets

  2. Determine the caloric adequacy of an infant's diet. (CP)

  3. Provide nutritional advice to families regarding the following: (CP)

    • Breastfeeding vs. formula feeding

    • Addition of solids to an infant's diet

    • Introduction of cow's milk to an infant's diet

    • Healthy food choices for children and adolescents

    • Exercise and TV or video viewing and their effect on obesity

Processes
All students on the Pediatric Clerkship should see a patient or patients with self or parental concerns or questions about appropriate nutrition (e.g. failure to thrive, questions about breast vs. bottle feeding, questions about switching to formula, when to add solids). This can be in the context of a routine health care supervision visit.

 

PREVENTION

Rationale
Physicians routinely incorporate strategies for prevention of illness and injury into routine health supervision. Immunizations have resulted in a drastic reduction in the rates of certain infectious diseases. Injuries cause the majority of deaths in childhood and adolescence. Illness and injury prevention must be a prominent and recurrent theme during health maintenance and other health care visits. The American Academy of Pediatrics most medical groups no longer use the term "accident" as most childhood injuries are believed to be predictable and preventable.
Note: There is a significant amount of overlap with the Health Supervision portion of the curriculum. Poisoning is covered in a separate section. Domestic violence is also addressed in the sections on Behavior, Issues Unique to Adolescence, and Child Abuse.

Prerequisites

  • Knowledge of clinical epidemiologic concepts as they pertain to estimation of health risk and prevention of illness and injury.

  • Understanding of the impact that culture, socioeconomic status and environment have on illness and injury prevalence and patterns.

  • An understanding of childhood development in order to better understand risk and provide age appropriate prevention strategies.

Competencies

Knowledge

  1. Describe how risk of illness and injury change during growth and development and give examples of the age-and development-related illnesses and injuries. (CP)

  2. List the immunizations currently recommended from birth through adolescence and identify patients whose immunizations are delayed. (CP)

  3. Describe the rationale, and general indications and contraindications of immunizations. (CP) Explain how screening for family violence may serve as an important preventive health practice. (CP)

  4. Describe the key components of a pre participation sports physical. (M)

  5. Describe infection control precautions that help limit the spread of infectious diseases in patients and health care providers (e.g. handwashing, masks, and N-95 masks in patients with tuberculosis). (U)

Skills

  1. Provide age-appropriate anticipatory guidance for the following: motor vehicle safety, infant sleeping position, falls, burns, poisoning, fire safety, choking, water safety, bike safety, sexually transmitted diseases, firearms and weapons. (CP)

ISSUES UNIQUE TO ADOLESCENCE

Rationale
Adolescence represents the stage of human growth and development between childhood and adulthood. During this time, significant physical, cognitive, and psychosocial changes occur.
Prerequisites

  • Introductory communication and interviewing skills

  • Knowledge of the anatomy, physiology, and endocrinology related to growth and reproduction

A framework for understanding childhood development

Competencies
Knowledge

  1. Describe the unique features of the physician-patient relationship during adolescence including confidentiality and consent. (CP)

  2. Identify and describe the sequence of the physical changes of puberty (e.g. Tanner scale). (CP)

  3. List the components of health supervision for an adolescent, such as personal habits, pubertal development, immunizations, acne, scoliosis, sports participation, and indications for pelvic exam. (CP)

  4. Describe the common risk-taking behaviors of adolescents, such as alcohol and other drug use, sexual activity and violence (CP)

  5. Describe the contributions of unintentional injuries (CP), homicide (CP), suicide (CP) and HIV/AIDS (M) to the morbidity and mortality of adolescents.

  6. Describe the features of common mental health problems in adolescence, including school failure, attention deficit, body image, eating disorders, depression and suicide. (CP)

  7. Describe an approach to counseling an adolescent regarding sexual activity, substance abuse, and personal safety. (M)

  8. Describe the unique difficulties encountered by adolescents with chronic diseases, including adherence and issues of autonomy vs. dependence. (M)

Discuss the characteristics of early, mid and late adolescence in the terms of cognitive and psychosocial development. (M)

Skills

  1. Interview an adolescent patient, using the HEADSS method, to ask sensitive questions about lifestyle choices that affect health and safety (e.g. sexuality, drug, tobacco and alcohol use) (CP) and give appropriate counseling (M)

  2. Conduct a physical examination of an adolescent that demonstrates respect for privacy and modesty, employing a chaperone when appropriate. (CP)

  3. Conduct a pre-participation sports examination and demonstrate the key components of that examination necessary to clear an individual for participation in strenuous exercise (special senses, cardiac, pulmonary, neurological, and musculo-skeletal). (M)

  4. Conduct a health supervision visit for a healthy adolescent, incorporating a psychosocial interview, developmental assessment and appropriate screening and preventive measures. (M)

Processes
All students on the Pediatric Clerkship should see an adolescent patient or patients.

 

ISSUES UNIQUE TO THE NEWBORN

Rationale
The transition from intrauterine life to extrauterine independent existence is a major event: physiologically for the baby, emotionally for the family, and medically for the health care team. Physicians must have an appreciation for the physiologic changes a newborn experiences. The newborn has unique needs and vulnerabilities that are distinct from other periods of infancy. Most of the information covered in this section is pertinent in the first few hours and days of life. However, the newborn period extends through to the first month of life.
Prerequisites

  • Embryology

  • Fetal physiology

  • Knowledge of the basics of antepartum and intrapartum care, particularly maternal screening tests and common maternal complications that can affect the newborn.

Competencies

Knowledge

  1. Describe the transition from the intrauterine to the extrauterine environment, including temperature regulation, cardiovascular/respiratory adjustment, glucose regulation, and initiation of feeding. (CP)

  2. List the information from the history of pregnancy, labor, and delivery obtained from the parents or medical record that has implications for the health of the newborn. (CP)

  3. Describe how gestational age can be assessed with an instrument such as the Ballard scale and identify key indications of gestational maturity. (CP)

  4. Describe the challenges for parents adjusting to a new infant in the home. (CP)

  5. List the differential diagnosis and complications for the following common problems that may occur in the newborn

    • jaundice (CP)

    • respiratory distress (CP)

    • poor feeding (CP)

    • large and small for gestation infants (e.g. congenital infection) (CP)

    • "state" abnormalities which includes tremulousness, irritability, lethargy from causes such as drug withdrawal, hypoglycemia, sepsis (CP)

    • prematurity (M)

  6. Describe how gestational age affects risks of morbidity or mortality in the newborn period (for example lung disease, hypothermia, and glucose homeostasis) (M)

Skills

 

  1. Perform a complete physical examination of the newborn infant. (CP)

  2. Give parents of a newborn anticipatory guidance for the following issues: (CP)

    • the benefits of breast-feeding vs. formula for the newborn and mother

    • normal bowel and urinary elimination patterns

    • normal neonatal sleep patterns

    • newborn screening tests to include screens for metabolic and infectious conditions and hearing loss

    • appropriate car seat use

    • prevention of SIDS ("back to sleep"):

    • immunizations (e.g. HBV)

    • medications (e.g. eye prophylaxis and vitamin K)

    • the role of circumcision

Processes
All students on the Pediatric Clerkship should see one or more newborns and a newborn with jaundice.

MEDICAL GENETICS AND DYSMORPHOLOGY

Rationale
A physician should be able to distinguish between congenital disorders (disorders present at birth) that are genetic from those that are non-genetic, as well as recognize common genetic diseases presenting later in childhood. Genetic abnormalities may produce congenital malformations, metabolic disturbances, specific organ dysfunction, abnormal growth patterns, and abnormalities of sexual differentiation. New technology and knowledge of genetics have raised ethical questions that physicians and society will need to address.

Prerequisites

  • Knowledge of gene structure, regulation and function

  • Basic knowledge of the Human Genome Project and the role of genetic inheritance in multifactorial diseases, such as cancer, heart disease and diabetes

  • Basic mechanisms of Mendelian inheritance, multifactorial inheritance, the "carrier" state, incomplete penetrance, variable expression, and spontaneous mutations.

  • Basic embryology and teratology

  • Introductory history taking and physical examination skills

Competencies

Knowledge

  1. Describe the genetic basis and clinical manifestations of the following syndromes, malformations, and associations:

    • Common chromosomal abnormalities, (e.g. Trisomy 21 (CP), Turner syndrome (CP), Klinefelter syndrome (M)

    • Syndromes due to teratogens (e.g. fetal alcohol syndrome) (CP)

    • Other common genetic disorders (e.g. cystic fibrosis, sickle cell disease, hemophilia) (CP)

    • Single malformations with multifactorial etiology (e.g. spina bifida, congenital heart disease, cleft lip and palate)(M)

  2. List common medical and metabolic disorders (e.g. hearing loss, hypothyroidism, PKU, hemoglobinopathies) detected through newborn screening programs. (CP)

  3. Discuss the effects of maternal health and potentially teratogenic agents on the fetus and child, including maternal diabetes and age (CP), alcohol use (CP) illicit drug use (CP), and prescribed medications such as phenytoin, valproate, and retinoic acid (M)

  4. List common prenatal diagnostic assessments (e.g. maternal serum screening, amniocentesis, and ultrasonography) and understand their use (M)

  5. Describe the use of chromosome studies in the diagnosis of genetic disorders (M)

  6. Discuss the role of genetics in common multifactorial conditions (e.g. inflammatory bowel disease, pyloric stenosis, congenital heart disease, cleft lip, diabetes and cancer) (M)

Skills

  1. Use a family history to construct a pedigree (e.g., for the evaluation of a possible genetic disorder). (CP)

COMMON ACUTE PEDIATRIC ILLNESSES

Rationale
Patients often come to medical attention because of a specific problem or complaint. The physician must solve the problems posed by the patient using information obtained from the history, the physical examination and, when appropriate, laboratory tests and/or imaging studies. In the problem-solving process, the physician typically develops differential diagnoses for each of the problems identified. The diagnostic process demands knowledge of disease etiology, pathophysiology and epidemiology and of the patient's gender, ethnicity, environment and prior health status.
When the patient is an infant, child, or adolescent, the physician must also consider the effects of age, physical growth, developmental stage and family environment. Commonly occurring illnesses are first considered, but other, less common disorders may need to be included in the evaluation of various clinical problems.


Prerequisites

  • Pathophysiology of common diseases.

  • Fundamentals of epidemiology.

  • Principles of pharmacology including pharmacokinetics and pharmacodynamics, and indications for drugs.

  • Basic clinical data gathering skills.

Competencies

Knowledge

  1. List the age appropriate differential diagnosis for pediatric patients presenting with each of the following symptoms. (CP) (See appendix for CP and M level differential diagnosis)

    • Abdominal pain

    • Cough and/or wheeze

    • Diarrhea

    • Fever and rash

    • Fever without a source

    • Headache

    • Lethargy or irritability

    • Limp or extremity pain

    • Otalgia

    • Rash

    • Rhinorrhea

    • Seizures

    • Sore throat

    • Vomiting

  2. List the age appropriate differential diagnosis for pediatric patients presenting with each of the following physical findings. (CP) (See appendix for CP and M level differential diagnosis)

    • Abdominal mass

    • Bruising

    • Heart murmur

    • Hepatomegaly

    • Lymphadenopathy

    • Splenomegaly

    • Petechiae and/or purpura

    • Red or wandering eye

    • White pupillary reflex

  3. List the age appropriate differential diagnosis for pediatric patients presenting with each of the following laboratory findings. (CP) (See appendix for CP and M level differential diagnosis)

    • Anemia

    • Hematuria

    • Proteinuria

    • Positive Mantoux skin test (PPD)

  4. Describe the epidemiology, clinical, laboratory, and radiographic findings, of each of the core pediatric level conditions listed for each presenting complaint. (CP)

  5. Explain how the physical manifestations of disease (CP) and the evaluation (CP) and management (M) may vary with the age of the patient. Be able to give specific examples.

  6. Discuss the characteristics of the patient and the illness that must be considered when making the decision to manage the patient in the hospital or in the outpatient setting. (M)

  7. Describe the epidemiology, clinical, laboratory, and radiographic finding for each of the mastery level conditions listed for each presenting complaint. (M)

Skills

  1. Perform an age-appropriate history and physical examination pertinent to the presenting complaint of the child (see also Skills).

  2. Generate an age appropriate differential diagnosis and initial diagnostic and therapeutic plan for each patient presenting with one of the following symptoms, physical examination findings, or laboratory findings (see also Clinical Reasoning). (CP)

    Symptoms

    • Abdominal pain

    • Cough and/or wheeze

    • Diarrhea

    • Fever and rash

    • Fever without a source

    • Headache

    • Lethargy or irritability

    • Limp or extremity pain

    • Otalgia

    • Rash

    • Rhinorrhea

    • Seizures

    • Sore throat

    • Vomiting

Physical examination findings

    • Abdominal mass

    • Bruising

    • Heart murmur

    • Hepatomegaly

    • Lymphadenopathy

    • Petechiae and/or purpura

    • Splenomegaly

    • Red or wandering eye

    • White pupillary reflex

Laboratory tests

    • Anemia

    • Hematuria

    • Proteinuria

    • Positive Mantoux skin test (PPD)

Processes
All students on the Pediatric Clerkship should see a patient or patients with the following system or symptom based complaints: (see appendix)

  • Upper respiratory tract complaint e.g. sore throat, difficulty swallowing, otalgia

  • Lower respiratory tract complaint e.g. cough, wheeze, shortness of breath

  • Gastrointestinal tract complaint e.g. nausea, vomiting, diarrhea, abdominal pain

  • Skin or mucous membrane complaint e.g. rash, pallor

  • Central nervous system complaint e.g. headache, lethargy, irritability, fussiness

Fever without localizing findings

 

COMMON CHRONIC ILLNESS AND DISABILITY

Rationale
Pediatricians are more frequently being asked to care for children with chronic medical conditions and exacerbations of their chronic illness. Physicians will need to understand the long term medical needs, implications and complications of the disorder for the patient as well as the family.
Prerequisites
An understanding of the pathophysiology and epidemiology of the following chronic illnesses: allergies, asthma, sensory impairment, cerebral palsy disability, cystic fibrosis, sickle cell disease, seizure disorder, diabetes mellitus, childhood malignancy, AIDS.
Competencies
Knowledge

  1. Describe the clinical features of chronic medical conditions seen in children such as: (CP)

    • asthma

    • atopic dermatitis

    • cerebral palsy

    • cystic fibrosis

    • diabetes mellitus

    • epilepsy

    • malignancy (e.g. acute lymphocytic leukemia and Wilms tumor)

    • obesity

    • seasonal allergies

    • sickle cell disease

    • HIV/AIDS (M)

    • sensory impairment (M)

  2. Describe how chronic illness can influence a child's growth and development, educational achievement, and psychosocial functioning. (CP)

  3. Describe the impact that chronic illness has on the family's emotional, economic and psychosocial functioning. (U)

  4. Describe the impact of a patient's culture on the understanding, reaction to, and management of a chronic illness (U)

  5. Describe the contributions of each member of a multidisciplinary health care team in caring for children with a chronic illness. (M)

  6. Identify the key components of delivering "Bad News" in relation to chronic illness. (MU)

  7. Explain the management strategies for common chronic illnesses seen in children such as asthma, seasonal allergies, diabetes, and atopic dermatitis (M)

Skills

  1. Perform a medical interview and a physical examination in a child with a chronic illness that includes the (CP)

    • effects of the chronic illness on growth and development,

    • emotional, economic and psychosocial functioning of the patient and family, the

    • treatments used, including "complementary and alternative therapies."

Processes
Students on the clerkship should see one or more patients with one of the chronic medical conditions listed above. This can be in the context of an acute or routine visit.

 

Therapeutics

Rationale
Appropriate and successful treatment requires choice of the correct medication, the appropriate dose, and both a dosage form and a dosing regimen that will maximize compliance. The pharmacokinetics (absorption, metabolism, distribution and elimination) of medications change under the influence of growth and physiologic maturation. Child behavior and psychomotor development influence the form of medication dispensed and the expectation for compliance.
Prerequisites

  • Knowledge of general pharmacokinetics and pharmacodynamics

  • Knowledge of the physiologic and behavioral changes that occur during childhood

Competencies
Knowledge:

  1. Describe how to assess whether a drug is excreted in the breastmilk and safe to use by a breast-feeding mother. (CP)

  2. List medications such as aspirin, tetracycline, and oral retinoic acid that are contraindicated or must be used with extreme caution in specific pediatric populations. (CP)

  3. Describe the appropriate use of the following common medications in the outpatient setting, including when it is NOT appropriate to treat with a medication: (U)

    • Analgesics / antipyretics

    • Antibiotics

    • Bronchodilators

    • Corticosteroids

    • Cough and cold preparations

    • Ophthalmic preparations

    • Otic preparations

    • Vitamin / mineral supplements

  1. Select generally accepted pharmacologic therapy for common or life-threatening conditions in pediatric patients. (CP) These conditions could include:

Common conditions seen in ambulatory settings:

5. Describe the ways medication errors are systemically prevented. (U)

    • Acne

    • Acute otitis media

    • Allergic rhinitis

    • Asthma

    • Atopic dermatitis

    • Candida dermatitis

    • Fever

    • Impetigo

    • Streptococcal pharyngitis

    • Common conditions seen in hospitalized patients

    • Bronchiolitis

    • Life threatening conditions

    • Sepsis/meningitis

    • Status epilepticus (M)

Skills:

  1. Calculate a drug dose for a child based on body weight. (CP)

  2. Write a prescription e.g. for a common medication such as an antibiotic. (U)

  3. Negotiate a therapeutic plan with the patient and family to maximize adherence with the agreed upon treatment regimens and assess the family's understanding of the plan. (MU)

FLUID AND ELECTROLYTE MANAGEMENT

Rationale
All human beings need an uninterrupted supply of water, electrolytes, and energy. Excessive or diminished fluid intake or losses may lead to severe physiologic derangements, with significant morbidity and even mortality.

Prerequisites
Knowledge of the following:

  • Water and electrolyte distribution in body compartments.
  • The relationship between basal metabolic rate and daily water requirements.
  • Daily glucose requirements.
  • The role of the adrenal gland and antidiuretic hormone (ADH) in maintaining serum sodium and body water balance.
  • Pathophysiology of hypernatremic and hyponatremic dehydration.

Competencies
Knowledge:

  1. Describe the conditions in which fluid administration may need to be restricted (such as the syndrome of inappropriate ADH secretion, congestive heart failure, or renal failure) or increased (e.g. fever). (U)
  2. Describe the physical findings in hypovolemic shock and the approach to restoration of circulating fluid volume (i.e. "rescue" fluid infusion) (U)
  3. Describe the causes and consequences of fluid imbalances and electrolyte disturbances leading to dehydration and such conditions as hypernatremia, hyponatremia, hyperkalemia, hypokalemia, and severe acidosis. (U)

Skills:

  1. Obtain historical and physical finding information necessary to assess the hydration status of a child. (CP)
  2. Calculate and write orders for intravenous maintenance fluids for a child considering daily water and electrolyte requirements. (CP)
  3. Calculate and write orders for the fluid therapy for a child with severe dehydration caused by gastroenteritis to include "rescue" fluid to replenish circulating volume, deficit fluid, and ongoing maintenance. (CP)
  4. Explain to parents how to use oral rehydration therapy for mild to moderate dehydration. (CP)

POISONING

Rationale
Poisonings and ingestions are major preventable causes of childhood morbidity and mortality. Poisoning control centers across the U.S. receive more than millions calls a year regarding accidental and non-accidental ingestions and exposures to toxic materials.

Prerequisites

  • Knowledge of the routes of absorption of toxins including the gastrointestinal tract, the skin, and lungs.
  • An understanding that a relationship exists between the mechanism of injury, the child and the environment
  • The concept of therapeutic index

Competencies
Knowledge

  1. Describe the developmental vulnerability for poisoning and accidental ingestions in infants, toddlers, children, and adolescents. (CP)
  2. List the ages at which prevalence of unintentional and intentional poisonings is highest and the passive and active interventions that decrease the incidence of childhood ingestions (e.g. locks or safety caps). (CP)
  3. Describe the emotions of guilt and anxiety that may be present in the parent, caregiver or child at the time of ingestion. (CP)
  4. Describe the environmental sources of lead, the clinical and social importance of lead poisoning, and screening tools to identify children at risk for lead poisoning. (CP)
  5. Describe the acute signs and symptoms of accidental or intentional ingestion of acetaminophen (CP), iron (CP), alcohol (CP), narcotics (CP) PCP (M), tricyclic antidepressants (M), volatile hydrocarbons (M), and caustics (M).
  6. Describe the immediate emergency management of children with toxic ingestions e.g. acetaminophen (CP), iron (CP), hydrocarbons (M), and strong alkali (M).
  7. Describe the role of the Poison Control Center (1-800-222-1222) and other information resources in the management of the patient with an accidental or intentional ingestion. (CP)
  8. Describe the agents and acute signs and symptoms of intentional chemical (e.g. cholinergic) or biologic agents. (M)

Skills:

  1. Provide anticipatory guidance regarding home safety and appropriate techniques to prevent accidental ingestions (see also Prevention) (CP)
  2. Elicit a complete history when evaluating an unintentional ingestion or exposure to a toxic substance (including the substance, the route of exposure, the quantity, timing, and general preventive measures in the household) (U)
  3. Elicit a complete history surrounding the intentional ingestion of a toxic substance (including the substance, route of exposure, amount, timing, antecedent events, and stressors). (M)

PEDIATRIC EMERGENCIES

Rationale
All health care providers must be able to identify the infant, child, or adolescent with a medical emergency. A systemic and thorough approach to the seriously ill child may significantly reduce morbidity and mortality.

Prerequisites

  • Knowledge of the cardiopulmonary responses to decreased or relatively decreased intravascular volume.
  • Certification in basic cardiopulmonary resuscitation.

Competencies
Knowledge

  1. List the symptoms of and describe the initial emergency management of shock, respiratory distress, lethargy, apnea, and status epilepticus in pediatric patients. (CP)
  2. Describe the age-appropriate differential diagnosis and the key clinical findings that would suggest a diagnosis for each of the emergent clinical problems in the table below.
  3. Describe the clinical findings for each of the diagnosis to consider in the table below.

Pediatric Emergencies Table

Knowledge, skills, clinical reasoning, and informed decision making while crucial to a physician's practice of medicine, are insufficient to guarantee successful clinical interactions. A physician must have well-developed interpersonal skills that facilitate communication, and must also demonstrate attitudes, behaviors and beliefs that serve to promote the patient's best interest. Students can learn to be professional, at least to a certain degree, in the abstract, but will acquire professional characteristics most effectively through contact with physicians chosen to serve as role models. In order to be effective role models, however, faculty must undergo training in order to be able to explain their behaviors explicitly, to foster professionalism and humanism. Clerkship Directors should assure that faculty development occurs in this area. Ethical principles, likewise, while learned in the abstract, must be applied clinically; the importance of suitable role models cannot be overemphasized.

In particular, each student must recognize that pediatrics poses unique challenges to professional conduct and attitudes. The patient constantly changes as growth and development proceed. The patient's ability to participate actively in the clinical interaction progresses, as does his or her knowledge, experience and concerns. The adolescent presents specific challenges, including such issues as privacy, risk-taking behaviors, confidentiality and personal involvement with health. The role of parents in the clinical interaction, and their knowledge, experience, and concerns also develop and change as an individual child grows and as subsequent children are born. The way a physician communicates can have a lasting effect in how parents, children and adolescents handle situations and interact with the physician. Cultural, ethnic and socioeconomic factors also affect personal and family traits and behaviors, with varying effects on child rearing practices. Recognition of and respect for difference are important, yet the student must be alert for the child or adolescent at risk in different family environments, given that the physician's primary obligation is to promote the best interest of the patient.

Professional conduct extends to the educational process: Students have a personal responsibility for their own education and for development of life-long learning skills. They must interact with all staff, including their peers and their teachers, in a manner that demonstrates respect for each individual and that promotes personal and group learning.

Emergent Clinical Problem

Diagnoses to Consider
(Core pediatric level)

Diagnoses to Consider
(mastery pediatric level)

Airway Obstruction / Respiratory distress

Croup, bronchiolitis, asthma, pneumonia, foreign body aspiration, anaphylaxis

peritonsillar or retropharyngeal abscess

Altered mental status
(Delirium/lethargy)

Head injury, increased ICP, substance abuse, infection (encephalitis, meningitis), diabetic ketoacidosis, hypoglycemia, abuse, shock, hypoxemia.

intussusception

Apnea

acute life-threatening event (ALTE), seizures, and respiratory infections (RSV and pertussis), GERD, sepsis

cardiac dysrhythmias, breath holding spells

Ataxia

 

ingestion, infection, and tumor

Gastrointestinal bleeding

Meckel's diverticulum, fissure, intussusception

inflammatory bowel disease, allergic colitis, peptic ulcer disease

Injuries and accidents

Animal bites, minor head injury, nursemaids elbow

sprains and fractures, burns, near drowning, lacerations

Proptosis

 

tumor and orbital cellulitis

Seizures

Infection (i.e., meningitis or encephalitis), status epilepticus, febrile, ingestion, hypoxemia, shock, electrolyte disturbances

tumor

Shock

Sepsis, severe dehydration, diabetic ketoacidoses, anaphylaxis, congestive heart failure and ingestion.

Burns, neurogenic shock, ductal dependent heart lesions, and adrenal insufficiency

Suicidal Ideation

Depression (U)

 

Skills

  1. Demonstrate the appropriate anticipatory guidance to prevent life-threatening conditions (e.g. infant positioning for sudden infant death syndrome (SIDS), locks to prevent poisoning, and the use of car seats and bicycle helmets) (see also Prevention). (CP)
  2. Demonstrate the "ABC" assessment as a means for identifying who requires immediate medical attention and intervention. (U)

Processes
All students on the pediatric clerkship should see a patient or patients, real or simulated, with respiratory distress

 

CHILD ABUSE

Rationale
Abuse may include physical, sexual and/or emotional trauma or may occur in the form of neglect when caregivers fail to provide basic physical, psychological or medical needs. Recognition of abuse or neglect can dramatically affect a child's life. Students and other health care providers need to understand the medical, legal, and social implications of suspected abuse and recognize the role of the physician in preventing child abuse and family violence, through routine assessment of family dynamics, early identification of children at risk, and cooperation with community services that support families.

Prerequisites

  • Basic clinical data-gathering and communication skills with families and professionals.
  • Knowledge of the epidemiology of domestic violence including those factors that increase the risk of domestic violence.

Competencies
Knowledge

  1. List characteristics of the history and physical examination that should trigger concern for possible physical, sexual, and psychological abuse and neglect e.g. such as inconsistency in the history, unexplained delays in seeking care, injuries with specific patterns or distributions on the body, or injuries incompatible with the child's development. (CP)
  2. Describe the medical-legal importance of a full, detailed, carefully documented history and physical examination in the evaluation of child abuse. (CP)
  3. Discuss the concurrence of domestic violence and child abuse and describe markers that suggest the occurrence of family violence. (U)
  4. Describe the unique communication skills required to work with families around issues of maltreatment. (M)
  5. Summarize the responsibilities of the "mandatory reporter" to identify and report suspected child abuse. Know to whom such a report should be made. (M)

CHILD ADVOCACY

Rationale
Physicians have a variety of roles in child health, including a public health role wherein they serve as patient and family advocates. Since children are unable to advocate for themselves and many of their families are not empowered, physicians must advocate for them at the individual, local, national and global level.

Prerequisites
Understand the role of the physician as an advocate.

Competencies
Knowledge

  1. Describe barriers that prevent children from gaining access to health care, including financial, cultural and geographic barriers. CP
  2. Identify opportunities for advocacy during a health supervision visit. CP
  3. Describe critical components of partnering with the community members to promote child health. (M)
  4. Describe the types of problems that benefit more from a community approach rather than an individual approach. (M)
  5. Identify a specific pediatric healthcare issue and outline a potential approach to advocacy. (M)

 

APPENDIX 1. COMMON PEDIATRIC ILLNESS TABLE

For each presenting symptom, finding, or laboratory value the columns list the suggested differential diagnosis based on level of competence.

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

Cough and/or wheeze

Asthma

Allergic rhinitis

 

Bronchiolitis

Chlamydia pneumonia

 

Community acquired pneumonia

Cystic fibrosis

 

Croup

Gastroesophageal reflux (GERD)

 

Viral upper respiratory tract infection

Laryngomalacia and tracheomalacia

 

 

Pertussis

 

 

Tuberculosis

 

 

 

Fever without a focus

Bacteremia/sepsis

JRA

 

Meningitis

malignancy

 

Occult bacteremia

 

 

Urinary tract infection

 

 

Viral illnesses

 

 

 

 

Sore Throat

Group a streptococcal pharyngitis

Peritonsillar abscess

 

Mononucleosis

Retropharyngeal abscess

 

Postnasal drip

 

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

Viral upper respiratory tract infection

 

 

 

 

Otalgia

Otitis media, Acute and Recurrent

Dental caries

 

Otitis media with effusion

Foreign body of the canal

 

Otitis externa

Mastoiditis

 

 

Pharyngitis

 

 

TMJ syndrome

 

 

 

Rhinorrhea

Allergic rhinitis

Nasal foreign body

 

Sinusitis

 

 

Viral URI.

 

 

 

 

Fever and rash

Group A streptococcal infection

drug reaction

 

Kawasaki disease

JRA

 

meningococcemia

Lyme disease

 

viral exanthem

Rickettsial disease

 

 

Toxic shock syndrome

 

 

 

Abdominal pain

Appendicitis

Bowel obstruction

 

Constipation/encopresis

Cholecystitis

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

Gastroenteritis

Dysmenorrhea

 

HSP

Gastritis

 

intussusception

Incarcerated hernia

 

Pelvic inflammatory disease

Inflammatory bowel disease

 

Urinary tract infection/pyelonephritis

Malignancy

 

 

Malrotation and volvulus

 

 

Ovarian or testicular torsion

 

 

Pancreatitis

 

 

Peptic ulcer disease

 

 

pregnancy

 

 

 

Diarrhea

Gastroenteritis

Celiac Disease

 

 

Clostridium difficile infection

 

 

Encopresis

 

 

Inflammatory Bowel Disease

 

 

Malabsorption

 

 

Toddlers diarrhea

 

 

 

Vomiting

Gastroenteritis

Bowel obstruction

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

Gastroesophageal reflux

Congenital adrenal hyperplasia

 

Pyloric stenosis

Diabetic Ketoacidosis

 

UTI/pyelonephritis

Eating disorder

 

 

Hepatitis

 

 

Inborn errors of metabolism

 

 

Inborn errors of metabolism

 

 

Intracranial process
(increased intracranial pressure)

 

 

Meningitis

 

 

poisoning

 

 

Pregnancy

 

 

Volvulus/malrotation

 

 

 

Rash

Atopic dermatitis

drug reaction

 

Contact dermatitis

erythema toxicum

 

cellulitis

molluscum contagiosum

 

impetigo

warts

 

lice

 

 

monilial infections

 

 

scabies

 

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

seborrhea

 

 

urticaria

 

 

viral enanthem

 

 

viral exanthem

 

 

 

 

Limp or extremity pain

developmental dysplasia of the hip

Acute rheumatic fever

 

fracture

Henoch Schönlein purpura

 

Legg-Calve-Perthes disease

JRA

 

Nursemaid elbow

Lyme disease

 

Osgood Schlatter disease

reactive arthritis

 

Septic arthritis

sickle cell crisis

 

Slipped capital femoral epiphysis

 

 

transient synovitis

 

 

 

 

Headache

meningitis

Brain tumor

 

tension headache

concussion

 

 

hydrocephalus

 

 

increased intracranial pressure

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

 

metabolic disorders

 

 

 

Seizures

febrile seizures

idiopathic seizures

 

 

meningitis

 

 

post traumatic seizure

 

 

toxic ingestions

 

 

 

Bruising

trauma

coagulopathy

 

 

leukemia

 

 

 

Petechiae/purpura

ITP

leukemia

 

sepsis

coagulopathy

 

trauma

rickettsial infection

 

vasculitis

 

 

viral infections

 

 

 

 

Heart murmur

innocent murmur

anemia

 

 

CHF

 

 

myocarditis

 

 

PDA

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

 

valvular defects

 

 

 

Lymphadenopathy

Bacterial adenitis

Cat scratch disease

 

Streptococcal pharyngitis

HIV

 

Viral illnesses (general or specific such as EBV)

Kawasaki disease

 

 

Malignancy

 

 

Mycobacterial adenitis

 

 

 

Splenomegaly

Malignancy (e.g. leukemia)

Hemolytic anemia

 

Mononucleosis

Sickle cell anemia (infancy)

 

 

Systemic infectious diseases

 

 

 

Hepatomegaly

hepatitis

congestive heart failure

 

 

inborn errors of metabolism

 

 

systemic infectious diseases

 

 

 

Abdominal mass

hydronephrosis

 

 

malignancy

 

 

pregnancy

 

 

stool

 

Presenting symptom, finding, or laboratory value

Core pediatric level

Mastery level

 

 

 

White pupillary reflex

cataracts

 

 

retinoblastoma

 

 

 

 

Red or wandering eye

conjunctivitis

allergy

 

strabismus

esotropia

 

 

exotropia

 

 

foreign body

 

 

trauma

 

 

 

Anemia

iron deficiency anemia

anemia of chronic disease

 

sickle cell anemia

bone marrow failure

 

thalassemia

hemolytic anemia

 

 

hemolytic uremic syndrome

 

 

malignancy

 

 

 

Hematuria

glomerulonephritis

benign familial hematuria

 

trauma

hemolytic uremic syndrome

 

UTI

hypercalciuria

 

 

 

Proteinuria

nephrotic syndrome

transient proteinuria

 

orthostatic proteinuria

glomerulonephritis

 

 

 

Positive Mantoux skin test

latent tuberculosis

non-tuberculosis mycobacterial infection

 

active tuberculosis

 


 

Didactics:

CLINICAL PROBLEMS

Topic

Instructions

File

Clinical Problems 1-18

Review each Clinical Problem in advance of the lecture.
You are responsible for participating in group discussions and
solving the problem during the lecture.

Clinical Problems

 

EBM

Topic

Instructions

File

Course Objectives

 

EBM_Objectives

For the Clinician

Read prior to EBM 2

EBM for the Clinician

CAT

 

CAT Instructions
CAT Example
CAT Template

Basic Stats for EBM

 

Basic_EBM.pdf

Users Guides to Med. Lit.

 

Users_Guide_Med_Lit

 

ETHICS

Topic

Instructions

File

Children as Patients

Read prior to the lecture

Children_as_Patients

Case Conferences

The current inpatient teams will each prepare an ethics case
for presentation during the lecture using the format provided.

Ethics_Conferences

 

TEAM BASED LEARNING

Topic

Instructions

File

Team Based Learning

These materials should be read prior to the Team Based Learning Seminar. All of these materials are available at the Merck Manuals Online Medical Library at http://www.merck.com/mmpe/index.html under Pulmonary Disorders.

Pulmonary Disorders, Asthma
Drug Treatment of Chronic Asthma (Table 2)
Flow Rates, Lung Volumes, and Flow-Volume Loops

GENERAL

     

Fluid Therapy

The articles should be read prior to the lecture.

Fluids_Deficit
Back to Basics
Fluid and Electrolytes

Immunization

 

Medstud Vaccine
Immunization schedule 09

Inpatient Floor Orientation

 

 

Welcome to Our Neighborhood

 

Neighborhood

SPECIALTIES

Effects of Radiation on Children

Read Student Module prior to the session

Medical Student Module 2010 PDF

Otitis Media

Review the Patient Evaluation portion of the website prior to the lecture.
This will be an interactive session and you are expected to actively participate in discussions and solving the cases presented.

Website Link

Review prior to the seminar

AOM Guideline Pediatrics

Huh, What did the doctor say?
Effective Communication Across the Continuum

Each student must prepare two different patient case write-ups (from their peds rotation) that they can present.

  • Please pick a fairly straightforward, simple case.
  • Outpatient students, please select a straightforward sick visit case.

HL Case Prep Form

Arrhythmias

 

Arrhythmias

Child Maltreatment

 

Acute Care Symposium

Congenital Heart Disease

 

Congenital_Heart

Endocrinology

 

Precocious_Puberty

Gastroenterology

 

Abdominal_Pain

Gastroenterology

 

Basics of Constipation

Genetics

 

MEM_Dysmorphology

Infant & Child Nutrition

 

Normal Infant Outline
Normal Nutrition

Malnutrition (Over/Under Nutrition)

 

Malnutrition_children

Radiology

 

GI_pediatricians

Rash Rounds

 

 

TEACHING ROUNDS (Inpatient Teams)

ID Rounds

Each Team must select 2-3 inpatient cases which they would like to discuss/review with Dr. Sherman Alter

-

Neurology Rounds

With Dr. Nadir Khan

-

Nephrology Rounds

With Dr. Abiodun Omoloja

-

PICU Rounds

with Dr. Patel

-


 

Preceptor Handouts:

Files

Feedback: giving better than what you got PDF

The 5 W’s: Precepting on the Go PDF


 

Feedback: giving better than what you got

What is Feedback?

  1. “Information a system uses to make adjustments in reaching a goal” [Ende]
  2. Intended to improve performance – in medicine, to sharpen clinical skills
    • Provides a link between instruction and assessment
    • Response to an event or occurrence, whether event is good or bad
  3. Feedback ≠ Evaluation
    • Feedback presents information, not judgment; it is formative in intent
    • Evaluation is summative; a grade – to what extent a person did or did not meet a set of established goals
  4. Without feedback, incorrect or ineffective behaviors unwittingly continue

Principles of Effective Feedback

  1. Well timed and expected
    • Set aside time for feedback and inform the learner well before it will occur
    • Avoid situations that add additional stress for giver or receiver
      • When one is angry about issue to be improved
      • When one does not have all the facts about issues
      • Post-call as sleep deprivation or preoccupation diminishes effectiveness
  2. Based on first-hand data or specific performances
    • Use “I-messages” to convey ownership of information
    • Any important aspect of learner’s overall job is worthy of inclusion as feedback
    • If a subjective opinion about their performance, be sure to offer it as such
  3. Focuses on the behavior, not the individual
    • Offer an informed, objective appraisal of performance
    • Identify clinical skills or actions the learner can work on and improve
  4. Positive when deserved; negative to help learner improve
    • Should encourage a learner to do better by offering unrecognized opportunities
    • Do not confuse positive feedback with complimenting. Reinforce those behaviors you wish to solidify – “Catch ‘em being good!”
    • Negative feedback should not be perceived as critical of the individual or destructive to their self worth

 

Delivering the message

  1. Be proactive – observe with feedback in mind; know th
  2. Begin session with learner's assessment of their own performance
    • Use “Reflective Listening” to help learner reach her/his own conclusion
  3. Offer feedback using the principles outlined
  4. Provide time for mutual problem solving
    • Be sure of the learner’s recognition of the problem
    • Ask learner to offer solutions. Be prepared with your own possible solutions
    • Negotiate a plan for resolution
  5. Summarize the important issues and ensure mutual understanding exists
    • Make a commitment to follow-up on feedback and proposed solution

The Two-Minute Drill --- Skipped the first part? Read this: Bylund, C. Director, ACGME Outcome Project, New York-Presbyterian http://library.cpmc.columbia.edu/cere/web/ACGME/doc/Giving_Feedback.pdf

Remember 6 characteristics of effective feedback:

  • Focus on specifics
  • Non-judgmental
  • Timely
  • Objective
  • Limited
  • Expected

Ask – Tell – Ask

  • Ask learners how they think they did/are doing
  • Tell learners what you observed
  • Ask learners how you can help them improve

Selected References

⇒ Ende J. Feedback in Medical Education. JAMA 250:6, 777-81, 12 Aug 83

Johnson C, First L. Resident Teaching: A Manual to Make It Successful. Office of Educational Development, Harvard Medical School, 1990.

Whitman NA, ed. Preceptors as Teachers: A Guide to Clinical Teaching. Univ of Utah, 1984

Woolliscroft JO. Teaching and learning in the ambulatory setting. Acad Med. 64(11):644-648, 1989.


 

Sample Documentation: