PEDIATRIC CLERKSHIP CORE CURRICULUM

SKILLS

I. Conduct a Patient/Parent Interview

• Obtain a history from a second party (parent), as well as directly from the patient
• Use different styles of questioning - open ended, directed, follow-up and summary.
• Communicate information to parents/patients.
  • Insure that both the child and the parent understand the diagnosis and treatment, and have an opportunity to ask questions.
  • Incorporate anticipatory guidance as a part of health supervision visits and discharge from the nursery.
  • Direct an interview and exam for an acute specific complaint, or for a specific purpose (e.g., evaluation of heart disease, preschool physical and pre-sport physical, etc...)

   

II. Perform a physical exam

• Adjust the approach to the exam using the patient's age.
  • Adjust the content, sequence and focus of exam based on the patient's age.
  • Assess the child's developmental level, modify the exam accordingly, and use strategies to improve rapport with the patient
• Demonstrate age specific exam skills for the:
  • Newborn:
    • assess the stability of vital functions, e.g. respirations, heart rate, temperature, feeding and stooling.
    • assess and interpret APGAR scores.
    • assess infant maturity.
  • Toddler, pre-school child
    • use techniques for building rapport with children who have stranger anxiety.
    • assess motor, language, and social development
  • Adolescent:
    • assess and stage secondary sexual characteristic
• Measurement/Recording:
  • Measure height, weight, and head circumference
  • Plot and interpret data on growth chart

 

• Specify how specific parts of the physical exam change with the patient's age and differ from the adult, including:
  • Obtain vital signs i.e., heart rate, respiratory rate, blood pressure, and temperature. Specify how normal values change for different ages.
  • Elicit newborn reflexes and state when they disappear.
  • Examine the tympanic membranes of an infant and child and identify abnormal hearing.
  • Examine the eyes for strabismus and identify an abnormal light reflex and/or abnormal visual acuity
  • Palpate nodes and specify the area(s) they drain; identify nuchal rigidity.
  • Distinguish between inspiratory and expiratory obstruction.
  • Auscultate for murmurs and palpate femoral pulses.
  • Palpate the abdomen for:
    • the liver
    • the spleen
    • abdominal masses
    • assess for rebound tenderness
  • Perform a rectal exam when indicated
  • Examine hips in the newborn and the young infant. Identify arthritis and abnormal gait
  • Identify skin disorders:
    • jaundice
    • petechiae
    • urticaria
    • vesicles
    • morbilliform rashes

III. Written and verbal communication skills

• Produce a written record of the history and physical examination.       

               The record must:

• Identify the chief complaint
• Chronologically organize the present illness.
• Specify the past history with specific emphasis on areas which are unique to pediatrics, to include:
  • neonatal history (birth weight, approximate gestational age, complications of pregnancy in mother, exposure to drugs, alcohol, medications, infections and complications of the newborn period such as prematurity, respiratory distress, jaundice, infections).
  • immunizations
  • development (6-7 milestones to ask about - social smile, roll over, sit alone, transfer object, stand alone, walk, say first words)
  • diet (breast fed, formula)
• Detail a review of systems
• Document the physical exam to include patient's appearance, vital signs, height, weight, head circumference, and percentiles.
• Complete a problem assessment:
• Define and assess each problem.
• Develop a plan to evaluate and treat each problem
• Plan for work-up and treatment for each problem
• Give an oral presentation that includes the essential elements of the patient's history in a chronological sequence and a summary of the pertinent physical exam findings.

IV. Problem solving skills

• Identify the medical problems during the history and physical exam
• Recognize patterns of illness sharing a unified etiology (e.g. fever, vomiting, irritability or fever and refusal to walk or pallor and petechiae...)
• Develop a differential diagnosis for each problem or group of problems which seem to logically group together and describe how age affects the differential diagnosis
• Describe the usefulness of laboratory tests which may help to confirm or disprove the clinical hypothesis for the illness under consideration.
  • State how normal values change with age
  • Discuss cost versus usefulness, limitations. and costs of various studies
• Discuss the usefulness, limitations and costs of various studies
• Interpret basic studies such as the chest X-ray
• Discuss the role of consultants as adjuncts to patient management

ATTITUDES

The student should possess specific attitudes desirable in a physician. Specifically, the student should acquire the following attitudes:

• Caring and compassion
• Commitment to work and learning
• Ethical sensitivity
• Moral integrity
• Cultural sensitivity
• Enthusiasm for patient care
• Ability to work as a team member
• Communication skills
• Commitment to the principle of disease prevention
• Respect for patients, family members and other health care workers
• Respect for other's opinions

KNOWLEDGE

Throughout his/her learning, the student should acquire and use knowledge of the mechanisms and developmental variations in normal values, disease manifestations. By the end of the clerkship, the student should, at a minimum, be able to:

I. Growth

• Demonstrate ability to plot accurately height, weight, and head circumference measurements in a growth chart.
• Discuss the significance of growth percentiles, with particular attention to an appreciation of why growth is a good index of health.
• Discuss the adverse effects on growth in intrauterine factors, malnutrition, maternal deprivation and social/cultural factors.

II. Development

• Describe the developmental changes that occur as the preterm baby matures.
• Identify and discuss major developmental milestones and developmental assessment using the Denver II Test.
• Discuss at least one developmental disorder.
• Discuss the concept of cognitive and emotional maturation.

III. Health Maintenance

• Discuss the importance of "health maintenance" or well-child visits.
• State the recommended schedule for well-child visits for ages birth to 18 years, and list ideas for anticipatory guidance for each age.
• List the routine schedule of childhood immunizations and which vaccines are given, their common side effects and contraindications to their administration.
• List when lead levels, blood pressure checks, vision testing and hematocrits are recommended.

IV. Nutrition

• Describe the importance and benefits of breast feeding.
• Counsel and provide emotional support a breastfeeding mother.
• Describe what constitutes a normal diet at different age groups and list the caloric requirements for growth at different ages.
• Describe common nutritional disorders in the US including iron deficiency anemia and obesity.
• State common food formulas for infants and their use and limitations.
• Describe the causes of failure to thrive.

V. Fluids and Electrolytes

• Recognize and clinically evaluate dehydration.
• Write maintenance fluid orders for any pediatric patient with normal renal function.
• Write fluid orders (both intravenous and oral) for uncomplicated gastroenteritis.
• Describe basic physiologic principles and apply them in the management of acute dehydration and acute metabolic acidosis.

VI. Common Pediatric Illnesses

The following list identifies the problems that commonly prompt patients to seek medical care (i.e. presenting complaints or symptom complexes).  Each complaint, diagnosis, physical finding/ laboratory test result (problem) is accompanied by a list of the most common related diagnoses as well as a list of less common but significant other diagnoses that may need to be considered.  Although more rare conditions may occasionally need to be considered, they are not included in this core list.

VII. Physical Findings/Laboratory Findings

The following section deals with the more common physical findings that merit further exploration. Sometimes the effort is to determine if a normal variant or minor vs. significant disease is occurring.  The list is not exhaustive, but the primary emphasis is on diagnoses unique to pediatrics.

VIII. Other Pediatric Problems

• Describe the indications for prophylaxis for bacterial endocarditis.
• Describe the presentation and principles of treatment of diabetes mellitus.
• Describe the content of the newborn disease screen and interpret screening results for hypothyroidism.
• Develop an organized approach to the dysmorphic child.
• Evaluate the child with hypertension.
• Describe disorders of altered tone and reflexes and recognize upper versus lower motor neuron disorders.
• Evaluate the child with recurrent infections.
• Recognize the different forms of shock and describe the principles of management.
• Recognize and evaluate respiratory failure in children.
• Describe normal growth patterns and recognize deviations from these patterns.

IX. Unique Issues of the Newborn

• Assign APGAR scores.
• Recognize and assess respiratory distress in the newborn.
• Recognize and assess cyanosis in the newborn.
• Recognize and assess pallor in the newborn.
• Recognize the features of congenital infections.
• Recognize and assess shock in the newborn.

X. Unique Issues of Adolescents

• Assess physical growth and development.
• Describe different stages of acne and approaches to its treatment.
• Screen adolescents for the presence of scoliosis.
• Give anticipatory guidance regarding adolescent pregnancy and its effects, birth control, sexually transmitted diseases, drugs, alcohol, accident prevention and firearms.

XI. Behavioral Problems

• Interact with patients referred for behavioral/emotional problems including obtaining a non-judgmental history and beginning to develop a plan for further evaluation and treatment.
• Describe developmental patterns of child behavior, including colic, sleep patterns, stranger anxiety, toilet mastery.
• Describe the impact on the family when the child has an acute, chronic or potentially fatal illness.
• Evaluate the child's social competence in the family, in school, and with peers.
• Observe and record parent-infant and parent-child interactions

XII. Poisoning

• Describe the extent and prevention of accidental poisoning in children less than 5 years of age.
• Describe the importance of anticipatory guidance in prevention.
• Obtain accurate history of poisonings while maintaining a non-judgmental approach.
• Identify common types of poisonings at various ages.
• Describe the general principles of management of ingested poisons.
• State the etiology, identification and management of the child with lead poisoning.

XIII. Accidents and Injuries

• State the extent to which accidents are responsible for more than one half of all childhood deaths.
• Describe the role and value of anticipatory guidance in prevention of the majority of diseases.
• State age-specific measures for accident prevention.

XIV. Pediatric Therapeutics

• Discuss dosing of medications in children based on differences in patient size and drug absorption, distribution, metabolism and excretion.
• Discuss why retin-A, tetracycline, the quinolones and chloramphenicol are not used in certain pediatric patients.
• Describe practical considerations related to drug administration and compliance in pediatrics.

XV. Child Abuse

• List risk factors in the family and child that puts a child at risk for abuse (non-accidental injury).
• Identify specific injuries or patterns of injury that should alert the physician to the possibility of child and/or sexual abuse.
• List the components of the work-up and immediate management of a child suspected of being abused.