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  1. 1. 1 Curriculum Table of Contents pp. Adolescent Medicine 2-6 Behavioral/Developmental Medicine 7 Community/Advocacy Block 8-11 Emergency Room 12-13 Medical Genetics 14-21 Hematology/Oncology 22 Pediatric Infectious Diseases 23-24 Pediatric Endocrinology 25-27 Nephrology/Urology 28 Pediatric Neurology 29-31 Pediatric Cardiology 32 Pediatric Gastroenterology 33 Pediatric Surgery 34 Pediatric ICU 35-36 Pediatric Pulmonology 37-38 Research Elective 39 General Pediatric Acute Care 40-42 Continuity Clinic 43-44 Inpatient Pediatric Wards 45-49 NICU 50-85 Well Born Nursery 86-93 Dermatology Elective 94 Pediatric Opthalmology 95 Orthopedics and Sports Medicine 96-97 Pediatric Radiology 98 Additional Curricular Experiences 99-100
  2. 2. 2 Adolescent Medicine (required) Teaching Objectives PGY 1, 2, or 3 1. Recognize normal and abnormal growth and development in adolescent patients and be able to obtain an adequate outpatient psychosocial history. 2. Become familiar with routine adolescent preventive care, including anticipatory guidance, GAPS guidelines, Bright Futures, immunization needs, and laboratory screening for teens. 3. Understand the fundamentals of anticipatory guidance for parents of teens. 4. Recognize the importance of accidents and non-accidental injuries in adolescent morbidity and mortality. Understand issues related to problem behavior theory. 5. Describe and explain issues of adolescent confidentiality, disclosure, and consent. 6. Be able to provide routine evaluation for sports participation. Understand the disqualifiers for sports involvement and when further evaluation is needed before allowing participation. 7. Recognize and be able to initiate treatment for the common sports injuries, including ACL tears, sprains, strains, and patellofemoral syndrome. 8. Be able to perform an adequate papanicalou smear and pelvic examination. Understand the guidelines for initiation of these procedures. 9. Understand and be able to teach the physiologic actions of the different forms of hormonal contraception. 10. Understand and teach the appropriate use of barrier contraception. 11. Understand the pathophysiology of menstrual disorders in adolescents, their evaluation, and their treatment. 12. Understand the pathophysiology and treatment of sexually transmitted infections and HIV in adolescents. 13. Be familiar with issues of adolescent pregnancy, including reasons for the problem and prevention. 14. Become comfortable with the evaluation of male health issues, including urethritis, epidiymitis, orchitis, testicular torsion, and prostatitis. 15. Become knowledgeable about adolescent mental health issues, including depression, ADHD, anxiety disorders, oppositional defiant disorder, eating disorders, and alcohol and other drug (AOD) abuse. Understand the basic evaluation and treatment of these issues and when referral to a psychiatrist/psychologist is needed. 16. Be familiar with issues of gay and lesbian youth. Course Description The resident physician will spend a minimum of 4 weeks on this rotation. Many will spend two months, one in the first year and one in the last year of residency. The rotation will involve working with adolescents in several locations and at various levels of patient maturity. Time will be spent at MU Student Health with Dr. Robinson and in the MU Adolescent Medicine Clinic with Drs. Lawson and Robinson. Residents will have approximately 6-7 clinical sessions per week, leaving two-three clinical sessions for reading. Occasional inpatient consultations will be done, though this rotation is primarily outpatient. Residents may be asked to give an evidence-based presentation on a topic in adolescent medicine. Finally, residents will do a training session with Dr. Robinson on evaluation of substance abuse in teens. In this session the resident will be taped interviewing a surrogate patient with a substance abuse problem. Emphasis will be placed on screening, evaluation, and intervention, using the Stages of Change model of Prochaska and DiClemente.
  3. 3. 3 Requirements by Level of Training During the first adolescent medicine rotation (usually L-1 or L-2 years) the resident is expected, primarily, to become comfortable interviewing adolescent patients with various problems and issues. The resident is expected to read about the conditions he/she sees in clinic. During the second block in adolescent medicine the resident is expected to make certain he/she has become familiar with all of the teaching objectives he/she had not already covered in the first block on the rotation. References 1. English A. Kenney KE. State Minor Consent Laws: A Summary (2nd Edition). Chapel Hill, N.C.: Center for Adolescent Health and the Law; 2003. 2. Neinstein LS. Adolescent Health Care, a Practical Guide. Baltimore, MD.: Lippincott Williams and Wilkins; 2002. 3. AAP. Substance Abuse, A Guide for Health Professionals.: Elk Grove Village, IL. AAP. 2002. 4. AAFP et al. Preparticipation Physical Evaluation (3rd Edition). Minneapolis, MN.: The Physician and Sportsmedicine, a Division of McGraw-Hill Companies; 2004. 5. World Health Organization. Improving Access to Quality Care in Family Planning, Medical Eligibility Criteria for Contraceptive Use (2nd Edition). 2000. 6. Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology (5th Edition). Philadelphia: Lippincott Williams and Wilkins; 2004. 7. AAP. ADHD A Complete and Authoritative Guide. Elk Grove Village, IL. 2004. 8. AAP. Substance Abuse, a Guide for Health Professionals. Elk Grove Village, IL: AAP; 2002. 9. Hornbacher M. Wasted, a Memoir of Anorexia and Bulimia. New York, N.Y.: Harper Collins; 1998. 10. Fisher M, Golden NH, Jacobson MS. The Spectrum of Disordered Eating: Anorexia Nervosa, Bulimia Nervosa, and Obesity. Adolescent Medicine State of the Art Reviews. 14 (1); 2003. 11. Hatcher RA, et al. Contraceptive Technology. New York, NY: Ardent Media; 2004. 12. Hoppenfeld S, Hutton R. Physical Examination of the Spine & Extremities. Norwalk, CN: Appleton & Lange; 1976.
  4. 4. 4 Adolescent Medicine Curriculum Supplement EVIDENCE-BASED MEDICINE (EBM) Defined as “ the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” We need to: 1. determine why we manage particular conditions the way we do 2. identify unanswered questions Then find relevant, up-to-date medical information and appraise its validity. Clinical decision = External clinical evidence (Research) + Clinical expertise + Patient/family characteristics Using EBM in practice 1. Devise the question a. Patient or problem b. Intervention (a cause, prognostic factor, or treatment) c. Comparison intervention (if necessary) d. Outcome 2. find the best evidence a. search for relevant journal articles b. use EBM summaries prepared by others c. accept clinical practice guidelines based on EBM strategies 3. critically evaluate the information for validity and clinical relevance 4. apply the evidence, follow-up, and reevaluating the clinical decision EBM TUTORIAL** Duke University/University of North Carolina ( EBM DATABASES AND SITES Ovid Technologies ( Contains access to the Cochrane Database of Systematic Reviews and Best Evidence. *Health Sciences Library (University of Missouri) Clinical Evidence – produced by BMJ Publishing Group EBM Reviews – ACP Journal Club EBM Reviews – Cochrane Central Register of Controlled Trials – bibliographic database of definitive controlled trials
  5. 5. 5 **EBM Reviews – Cochrane Database of Systematic Reviews – full text of the regularly updated systematic reviews of the effects of healthcare prepared by The Cochrane Collaboration EBM Reviews – Database of Abstracts of Reviews of Effectiveness – structured abstracts of systematic reviews from all over the world EBM Reviews Full Text All EBM Reviews National Library of Medicine ( American College of Physicians ( Subscription service to two secondary publications – ACP Journal Club and Evidence Based Medicine (staff sifts through over 50 journals, etc for articles of high scientific merit and includes an expert commentary. *Cochrane Collaboration ( Subscription service to an international collaboration of centers that prepare, maintain, and promote the accessibility of systematic reviews of the effects of health care. Evidence-based Intensive Care ( University of Michigan ( EVIDENCE-BASED GUIDELINES American Academy of Pediatrics ( Publishes policy statements and evidence-based practice parameters (internet versions and hardcover book). National Guideline Clearinghouse ( Guide to Clinical Preventive Services ( JOURNAL ARTICLE SERIES Users’ Guides to the Medical Literature: JAMA 1993;270:2093, 2096, 2598 1996;275:554, 1435 1994;271:59, 389,703, 1615 1997;277:1232, 1552, 1802 1994;272:234, 1367 1998;279:545 1995;273:1292, 1610 1999;281:1214, 1836, 2029 1995;274:570, 1630, 1800 1999;282:67, 771, 1371
  6. 6. 6 Critically Appraised Topic (30-minute limit) Date: Clinical Question: Patient or problem - Intervention - Comparison - Outcome - Clinical bottom line(s): Search Strategy: Evidence Study or Resource Type: Patient Characteristics: Results: * Quality Issues: *Include clinically relevant measures such as number needed to treat for treatment studies, sensitivity, specificity, and predictive values for diagnostic studies.
  7. 7. 7 Behavioral/Developmental Pediatrics (required) Goals and Objectives PGY 1 or PGY2 1. Become familiar with normal and abnormal child development, including cognitive, language, motor, social, and emotional aspects. 2. Understand the importance and process of referral for developmental or behavioral problems and the various resources available in the community. 3. Participate in diagnosis and management of behavioral and developmental problems of varying complexity. This includes psychosocial and medical aspects of care. 4. Become familiar with developmental and psychosocial screening techniques. 5. Develop the ability to identify children at risk for developmental problems, abuse, and family dysfunction. 6. Become adept at interviewing patients and families to assess developmental history, social history, and family structure, including the circumstances and complexity of adoptive and foster care. Course Description Development/Behavioral Pediatrics is a 4 week rotation. Residents on this rotation are expected to become part of the development team and participate in the clinical and academic pursuits of the division. Responsibilities include, but are not limited to: ward consultations, developmental screening exams, development clinics, assigned readings, independent study. A packet for readings will be provided at the start of the rotation. Residents and rotators will be expected to participate in all of these activities equally. The resident will primarily work with Dr. Tracy Stroud, and Ellen Horwitz, PhD; He/she may also spend some time with child neurology. References: Levine: Developmental-Behavioral Pediatrics (Textbook) Baird and Gordon: Neurological evaluation of infants and children. Encounters with Children Dixon, Stein 1992 AAP Diagnostic and Statistical Manual for Primary Care (DSM-PC) 1996
  8. 8. 8 Community/Advocacy Block (required) PGY-3 (Pediatrics) or PGY-4 year (Med-Peds) Goals and Objectives 1. Become familiar with community resources that assist families in providing for their child with special needs. 2. Learn how to refer children to and access specific programs for evaluation of speech therapy, learning, physical therapy, occupational therapy, and hearing. 3. Visit the sites where various therapies and services are provided to observe activities in these environments. 4. Understand the problems of underserved children in the community and how to improve the care they receive. 5. Understand how to care for children in a culturally sensitive manner. 6. Understand the role of the pediatrician in the school and daycare settings. 7. Visit community-based primary care treatment settings for children. 8. Understand the role of the pediatrician in the legislative process by visiting with legislators in Jefferson City, MO. 9. Learn to create partnerships and medical homes for children with special needs. 10. Observe, monitor, and participate in SAFE evaluations of abused children. Course Description The senior resident will visit several sites in the community in which service to children are rendered. These will include, but not be limited to, the following: The Head Start Program Department of Family Services School for the Blind School for the Deaf Local homes for abused or neglected children Therapy for Kids The Health Department Clinics A Home Health Service for Children Elementary School, Junior High School, and High School nurses Juvenile Justice Facility for incarcerated youth A Health Center for the Mennonite or Amish Communities A Health Center for area Hispanic Communities The Missouri State Legislature (if in session) with one of the “Doctor’s of the Day” or visit with one or more legislators regarding advocacy The Child Advocacy Center (where SAFE examinations are done). The course may be done in a community in which a resident physician plans to settle, if permission is given by the program director. However, a similar schedule to the one above will need to be kept. Alternate scheduled experiences by resident physicians ( e.g., working on an Indian Reservation or going on a medical missions trip for part of the block) will also be considered. Med-Peds resident physicians may split their time between programs that give services to adults as well as children.
  9. 9. 9 The resident physician, with the help of the program director and program coordinator, will schedule the above experiences. The resident is expected to read at least 15 of the resources below (most are short). All of these are in the journal Pediatrics and are easily found on the AAP website: (look for policy statements to R on main homepage). He/she should make an appointment with the program director to report on and discuss at least 4 of the articles below. Resources: Committee on Community Health Services. Health care for children of immigrant families. Pediatrics. 1997; 100 (1): 153-156. AAP. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002; 110 (6): 1304-1306 Committee on Pediatric Emergency Medicine. Access to pediatric emergency medical care. Pediatrics. 2000; 105 (3): 647-649. AAP.All-Terrain Vehicle Injury Prevention: Two-, Three-, and Four-Wheeled Unlicensed Motor Vehicles. Pediatrics. 2000; 105 (6): 1352-1354. American Academy of Pediatrics Section on School Health: Residency training and continuing medical education in school health. Pediatrics. 1993; 92(2): 495-96. AAP. Assessement of Maltreatment of Children with Disabilities. Pediatrics. 2001. 108(2): 508-512. Committee on Children With Disabilities. Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs Pediatrics. 1999. 104 (4): 978-981. Committee on Adolescence and Committee on Early Childhood and Adoption, and Dependent Care. Care of Adolescent Parents and Their Children Pediatrics. 2001. 107 (2) : 429-434. Committee on Adolescence.Care of the Adolescent Sexual Assault Victim. Pediatrics. 2001. 107 (6) : 1476-1479. Committee on School Health. Corporal Punishment in Schools Pediatrics. 2000. 106 (2) : 343. Committee on Pediatric Workforce. Culturally Effective Pediatric Care: Education and Training Issues. Pediatrics. 1999. 103 (1) : 167-170. Committee on Early Childhood and Adoption and Dependent Care. Developmental Issues for Young Children in Foster Care Pediatrics. 2000. 106 (5) : 1145-1150. Committee on Child Abuse and Neglect and Committee on Bioethics. Forgoing Life-Sustaining Medical Treatment in Abused Children. Pediatrics. 2000. 106 (5) : 1151-1153.
  10. 10. 10 Committee on Children with Disabilities. Guidelines for home care of infants, children, and adolescents with chronic disease. Pediatrics. 1995. 96 (1) : 161-164. Committee on School Health. Guidelines for the Administration of Medication in School. Pediatrics. 2003. 112 (3) : 697-699. Committee on School Health. Health Appraisal Guidelines for Day Camps and Resident Camps. Pediatrics. 2000. 105 (3) : 643-644. Committee on Adolescence. Health Care for Children and Adolescents in the Juvenile Correctional Care System. Pediatrics. 2001. 107 (4) : 799-803. AAP. Health care for children of farmworker families. American Academy Pediatrics Committee on Community Health Service. Pediatrics. 1995. 95 (6) : 952-953. Committee on Early Childhood, Adoption, and Dependent Care. Health Care of Young Children in Foster Care. Pediatrics. 2002. 109 (3) : 536-541. Committee on Community Health Services. Health needs of homeless children and families. Pediatrics. 1996. 98 (4) : 789-791. Committee on School Health. Home, Hospital, and Other Non-School-based Instruction for Children and Adolescents Who Are Medically Unable to Attend School. Pediatrics. 2000. 106 (5) : 1154-1155. Committee on Pediatric Workforce. Nondiscrimination in Pediatric Health Care. Pediatrics. 2001. 108 (5) : 1215 Committee on Sports Medicine and Fitness and Committee on School Health. Organized Sports for Children and Preadolescents. Pediatrics. 2001. 107 (6) : 1459-1462. Committee on School Health. Out-of-School Suspension and Expulsion Pediatrics. 2003. 112 (5) : 1206-1209. Committee on Sports Medicine and Fitness and Committee on School Health. Physical Fitness and Activity in Schools. Pediatrics. 2000. 105 (5) : 1156-1157. Committee on Pediatric AIDS. Planning for Children Whose Parents Are Dying of HIV/AIDS. Pediatrics. 1999. 103 (2) : 509-511. Committee on Nutrition. Prevention of Pediatric Overweight and Obesity. Pediatrics. 2003. 112 (2) : 424-430. Committee on Sports Medicine and Fitness and American Academy of Ophthalmology Committee on Eye Safety and Sports Ophthalmology. Protective eyewear for young athletes. Pediatrics. 1996. 98 (2) : 311-313. Committee on Children With Disabilities. Provision of Educationally-Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions. Pediatrics. 2000. 105 (2) : 448-451.
  11. 11. 11 Committee on Children With Disabilities and Committee on Psychosocial Aspects of Child and Family Health. Psychosocial risks of chronic health conditions in childhood and adolescence. Pediatrics. 1993. 92 (6) : 876-878. Committee on Environmental Health. Radiation Disasters and Children. Pediatrics. 2003. 111 (6) : 1455-1466. Committee on Injury and Poison Prevention. Reducing the Number of Deaths and Injuries From Residential Fires. Pediatrics. 2000. 105 (6) : 1355-1357. Committee on Bioethics. Religious Objections to Medical Care. Pediatrics. 1997. 99 (2) : 279-281. Committee on Sports Medicine and Fitness. Risk of Injury From Baseball and Softball in Children. Pediatrics. 2001. 107 (4) : 782-784. Committee on Injury and Poison Prevention. School Bus Transportation of Children With Special Health Care Needs. Pediatrics. 2001. 108 (2) : 516-518. Committee on School Health. School Health Assessments. Pediatrics. 2000. 105 (4) : 875-877. Committee on School Health. School Health Centers and Other Integrated School Health Services. Pediatrics. 2001. 107 (1) : 198-201. Committee on School Health and Committee on Injury and Poison Prevention. School Transportation Safety. Pediatrics. 1996. 97 (5) : 754-757. Committee on Injury and Poison Prevention. Skateboard and Scooter Injuries. Pediatrics. 2002. 109 (3) : 542-543. AAP. Sexuality Education for Children and Adolescents . Pediatrics. 2001. 108 (2) : 498-502. Committee on School Health. Soft Drinks in Schools. Pediatrics. 2004. 113 (1) : 152-154. Committee on Community Health Services. The Pediatrician's Role in Community Pediatrics. Pediatrics. 1999. 103 (6) : 1304-1306. Committee on Pediatric Emergency Medicine. The Role of the Pediatrician in Rural EMSC. Pediatrics. 1998. 101 (5) : 941-943. Committee on Children With Disabilities. The Role of the Pediatrician in Transitioning Children and Adolescents With Developmental Disabilities and Chronic Illnesses From School to Work or College. Pediatrics. 2000. 106 (4) : 854-856. Committee on Injury and Poison Prevention and Committee on Adolescence. The teenage driver. Pediatrics. 1996. 98 (5) : 987-990.
  12. 12. 12 Emergency Medicine (required) Goals and Objectives 1. To learn the approach of acute medical care in the Emergency Department setting. 2. Develop knowledge of appropriate triage of patients arriving in the ER. 3. Learn the aspects of acute stabilization of a critical patient in the ER. 4. Work in unison with the trauma team in the management of pediatric major trauma patients (Trauma codes, Class I and II trauma). 5. Learn the process and evaluation of trauma patients. 6. Become comfortable in the evaluation, diagnosis, and treatment of Class I and II medical problems. 7. Develop skills needed to management pediatric patients in the emergency department. These include, but are not limited to the following: Abdominal pain Laceration evaluation and repair Orthopedic injuries, including splinting, appropriate follow-up, and Salter-Harris fractures Diagnosis and treatment of sexually transmitted diseases Child abuse Evaluation and treatment of head trauma Gynecologic and obstetric treatment of the adolescent Appropriate use of sedation and procedure of sedation in the ER Overdoses and poisoning including treatment and antidotes Treatment of anaphylaxis Evaluation and treatment of burns Near drowning ALTE Course Description First year Pediatric residents will spend 4 weeks in the Emergency Department. Senior residents in Pediatrics and Med/Peds will work in the ER for 4 weeks. Requirements by Level of Training Senior residents will be given more responsibility for diagnosing and treating conditions seen in the ER and for making decisions about admission of patients seen. The senior resident will also be more involved with the care of trauma patients than will the intern, in terms of giving medical treatment advice to the surgeons. Senior residents are expected to see 10-12 patients per shift in the ER (depending on the conditions seen, of course. The resident might see many more than that if most of the patients have routine, non-threatening pediatric conditions and fewer if more patients are quite ill)., while interns will be expected to see approximately 8 patients per shift. Both interns and senior residents are expected to check out their patients to the attending physician in the emergency room. The ER will be covered by the pediatric service daily from 5 p.m. until 1 a.m. The resident on the ER rotation will be covered by other pediatric residents when he/she is off for the day. There is a procedural lab that is conducted by Terry Carlisle PA that the ER is expected to attend. There are also lectures provided during the month by the ER attendings. You should attend and participate in all provided lectures. Reading for this block is independent and should cover the topics noted above and other interesting cases that are encountered during the rotation.
  13. 13. 13 Emergency Room Addendum 1. It is the responsibility of the resident covering the ER to perform most of the initial work involved in the admission of pediatric patients to the ward or PICU. This includes determining whether the patient needs to be admitted (along with the ER attending, possibly after consulting the pediatric ward attending), informing the ward attending of the admission, calling the Admissions Office with info about the patient, writing orders and writing or dictating a note. The idea is to lighten the load on the ward team. If the ER resident is overwhelmed with other patients, it is reasonable to request the ward team to handle the admission, although this should not be routine. Conversely, if the ER is relatively light and the ward team is very busy, it is reasonable for the ER resident (with permission of the ER attending) to escort the patient to the ward/PICU and continue the workup (such as LPs, etc) there. Such procedures can be done in the ER, but the pediatric nurses on the 7th floor are more familiar with pediatric patients and procedures and at times may be less busy. 2. Discharge instructions: currently the standard is to use the computer discharge instructions or write your own. However, the computer has woefully inadequate pediatric instructions. Therefore we are currently working on compiling a file of common discharge diagnoses so that we as a department can provide current, appropriate instructions for our patients. In the meantime, it is strongly suggested that you hand write your instructions on the triplicate forms available. Remember, these instructions are being given to parents, you should NOT use abbreviations AT ALL. Something as simple as tsp. for teaspoons may be misinterpreted as tablespoons leading to an overdose of medication. Further, handwriting is crucial. Medico-legally, if it is written down but can’t be read, there is no leg to stand on. When writing over the counter medication doses be sure to clearly write the concentration of the medication that you are referring to and explain to the parent/caregiver to match these numbers to those on the label. For example, Tylenol comes in a variety of strengths; simply writing r teaspoon could be dangerous unless you state that you are referring to the children’s concentration of 160mg/5ml. Take nothing for granted. Finally, it is important to always include in writing when and why a patient should return or seek further medical attention. If you just tell a family to return if thus and such happens and they don’t and there is a bad outcome, you cannot prove you told them to return unless it is in writing. 3. In order to track our exposure as a residency program to Emergency Care in terms of diagnoses and numbers, a list of patients seen in the ER should be turned in to the chief residentso the next day. This can be done very simply by using the labels printed for each patient to be used to order labs. Affix a label from each patient to a sheet of paper and write the diagnosis next to it. At the end of your shift or the next day place the paper with all your labels in it in the chief residentst effectively. Resource AAP. APLS. The Pediatric Emergency Medicine Resource, 4th Edition. 2004. See Dr. Robinson to check book out.
  14. 14. 14 MEDICAL GENETICS ROTATION WELCOME TO RESIDENTS, FELLOWS AND STUDENTS Goals of the Medical Genetics rotation for residents and medical students 1. Develop a genetics knowledge base. a) How to take a genetic history. b) How to take a family history and analyze a pedigree. c) How to perform and interpret a dysmorphology exam d) Genetics readings - book list, journals, computer searches. e) Genetics network - where to refer and where to ask for help. f) Read one recent issue of American Journal of Medical Genetics or other Genetics Journal to learn about breadth of medical syndromes. 2. Genetic diagnosis: Solving complex clinical problems. a) Collect data - green sheet, medical records. Complete a genetics database green sheet on each patient. b) Organize data - problem list. c) Literature search - Computer competency in: OMIM; London Dysmorphology Database; Medline; Reprotox. d) Diagnostic plan - is there clinical testing available? e) Interpretation of genetic laboratory data: cytogenetics, metabolic, molecular e) Follow-up. 3. Long term clinical care plans for children with chronic problems. a) Team participation in order to understand the roles of genetics counselors, therapists, and education specialists. b) Interact with parents. c) Interact with other specialists. d) Generate a list of resources in Missouri (Regional Centers for the Developmentally Disabled, Early Intervention Programs, Genetic Disease Associations - Neurofibromatosis, Down Syndrome, etc.) e) Learn management protocols for genetic conditions. 4. Genetic Counseling: Learn what counseling entails, techniques and steps. a) Recurrence risk assessment. b) Options. c) Supportive counseling. 5.. Develop an appreciation and contribution to the genetics literature (for residents or students on one month rotations) a) Select one case or topic early in the rotation that may be suitable for publication. b)Complete a literature review including: texts, journals, computer search, and personal communication. c)Consider patient review of the University of Missouri "experience". d) Prepare an abstract suitable for submission to a meeting for presentation. e)Complete paper for publication, if possible. f) Present discussion of topic in Genetics Monday Rounds.
  15. 15. 15 MEDICAL GENETICS STAFF Clinical Staff Judith H. Miles, M.D., Ph.D. Clinical Genetics Cytogenetics Richard E. Hillman, M.D. Clinical Genetics Metabolic Genetics Stephen R. Braddock, M.D. Clinical Genetics Dysmorphology Teratology Dimitar Gavrilov, MD Genetic Counselors/Nurses/Dietitian Jennifer Kussman, M.S. - Genetic Counselor- Coordinate General Genetics Clinic, Hannibal and Kirksville Genetics Outreach Clinics, H.D. Presymptomatic Testing Program, and Down Syndrome Clinic Dawn Peck, M.S. - Genetic Counselor - Coordinate Metabolic Genetics Clinic, Versailles & Springfield Outreach Clinic Janda Bucholz, M.S.- Genetic Counselor-Prenatal Diagnosis & Counseling Coordinator Robin Troxell, M.S. -Genetic Counselor - Southern Missouri Outreach (Springfield, Poplar Bluff, Rolla). Donna LeBlanc, RN, MS, Certified Nurse Practitioner, - Southern Missouri Outreach Carrie Chou - Coordinator, MO Teratogen Information Service and Missouri Fetal Alcohol Syndrome Clinic Cyndy Jones, R.N. - Autism Clinic Nicole Takahashi - Autism Research Assistant Julie Grasela, R.D. - Metabolic Clinic Dietician Laboratory/Research Dennis Lubahn, Ph.D. - Molecular Biology, Biochemistry Charlotte Phillips, Ph.D. - Molecular Biology, Biochemistry Joyce Mitchell, Ph.D. - Director of Information Sciences, Asst Dean Merribeth Muskopf - Senior technologist, Metabolic Lab Office staff Diane Kirby - Administrative Assistant, Room NW507 Nayshea Rice - Senior Secretary, Clinic scheduling and organization, GOAS, files Kelly Arndt - Chief Clerk, MSAFP program and prenatal scheduling Donna Nale - Southern Missouri Regional Genetics Program Outreach
  16. 16. 16 GENETICS CALENDAR Monday: 1:00-3:00 Genetics Staffing (Genetics Library) 3:30-4:30 X-ray Rounds - 3rd Monday with Dr. Brown in Reading Room-Radiology (announced as scheduled) MRI Rounds - 1st Monday with Dr. Vaslow - MRI Reading Room Tuesday: 9:00-1:00 Prenatal Counseling Only Patients (MFM Clinic, UP Building) 12:00-1:00 Molecular Genetics Hot Topics Journal Club (Genetics Library) 9:00-5:00 Autism Clinic (Pediatric Clinic, UP Building) - Genetics and Psychiatric Medical Management Autism Clinic Wednesday: 8:00-12:00 Metabolic Clinic with Dr. Hillman (Pediatric Clinic - qo week) Outreach Clinics are often scheduled on Wednesday. 8:00-12:00 Prenatal Clinic Counseling/Procedures (MFM Clinic, UP Build) 1:00-4:00 Genetics Clinic (return patients only) - Dr. Braddock and Dr. Miles (Pediatric Clinic, UP Building) Thursday: 8:00-1:00 Genetics Clinic (Pediatric Clinic, UP Building) 1:00-5:00 Down Syndrome Clinic - third Thursday of the month (Pediatric Clinic) 1:00-3:00 Autism Clinic (return patients only for Dr. R. Hillman and Dr. Miles) - except every third Thursday (Peds. Cl.) Friday: 8:15-9:15 Grand Rounds 8:00-12:00 Prenatal Clinic Counseling/Procedures, MFM Clinic 8:30-12:00 Cleft Palate Clinic - Every third Friday (Pediatric Clinic) 8:00-3:30 FAS Clinic - 4th Friday of each month (Pediatric Clinic) 1:00-2:30 Prenatal Staffing and Preclinic (Genetics Library) CLINICS INFORMATION AND ASSIGNMENTS: * Obtain clinic patient assignments for the next week at the Friday 1:00 rounds and prepare by 1) reading the available files/charts, 2) reading about the disorder in appropriate Genetics books (not Nelson) which are in the genetics Library, 3)run a medline search and OMIM search and pull at least one paper that updates the information in the text book, 4) make a plan for what needs to be done in clinic for that patient.
  17. 17. 17 * Give your beeper number/home number and schedule to Diane Kirby when you start the rotation so it can be posted on Division black board. * Meet with Dawn Peck (NW503) on the first day of your rotation for orientation 1. Prenatal Diagnosis & Counseling Clinic - Tuesday for counseling only and Wednesday and Friday mornings for prenatal counseling with amniocentesis or other procedures. Patients may be scheduled throughout the week according to emergency situations. Overflow patients are scheduled Monday mornings. a) Attend at least one (if on genetics for one week) counseling appointment with one of the genetic counselors to become familiar with genetic history and prenatal diagnosis counseling. 2. Medical Genetics Clinic - Wednesday afternoon and Thursday morning a) Clinic for evaluation and follow-up of children and adults with genetic or metabolic diseases, dysmorphic features, mental retardation and birth defects. b) Work up at least one new patient each week and dictate comprehensive consultation report. 1. Green chart is given to Nayshea Rice and dictation is put in the transcriptionist work box 2. Genetic history must be completed (green form), along with the visit and diagnosis sheet (blue form). This information is recorded into the GOAS (Genetics Office Automated System.) c) See one to two follow-up patients. 3. Metabolic Clinic - every other Wednesday with Dr. Hillman, Dawn Peck and Julie Grasela. Obtain patient assignment from Dawn Peck.. 4. Genetics Outreach Clinic - Every other Wednesday. a) Work up one or two new patients and dictate consultation report. b) See one or two patients in follow-up. 5. Down Syndrome Clinic - 3rd Thursday afternoon of the month. 6. Cleft Palate Clinic -Third Friday of the month. Students and residents don’t generally attend because of time constraints for the evaluations but may observe if approved by Dr. Braddock. 7. FAS Clinic - 4th Friday of the month. Need permission from Dr. Braddock. 7. Autism Clinic - Tuesdays and Thursdays. Genetics and Psychiatric Autism Clinics - Miles, Hillman, Jones - Obtain patient assignment from Cyndy Jones INPATIENT CONSULTATIONS 1. See in-hospital consultations; do family history, dysmorphology exam, and formulate diagnostic plan and differential diagnosis. Diane Kirby or one of the counselors will page you with consults as they are received.
  18. 18. 18 2. Review with genetics staff before writing the consultation. 3. Complete blue consult sheet within 24 hours. 4. Complete green sheet on each patient and return to attending with copy of the consult. MEDICAL GENETICS CONFERENCES - Genetics Library 1. Clinical Genetics Rounds - Monday 1:00-3:00. All staff, residents and students present cases evaluated during previous week. 2. Prenatal Counseling Conference - Friday 1:00-2:30. 3. Pediatric Grand Rounds - 8:15 a.m. Friday. 4. Molecular Journal Club - Tuesday, noon - 1:00 pm. Each week a geneticist presents a recent search article to the group. 5. X-ray Rounds - 3rd Monday of the month with Dr. Brown in radiology booth. Give patient names and numbers to Diane Kirby for each film you want to review by the previous Friday (announced as scheduled). 6. MRI Rounds - 1st Monday of the month with Dr. Vaslow in MRI reading room. Give patient names and numbers to Diane Kirby for each film you want to review by the previous Friday (announced as scheduled). REFERENCE LIST - MEDICAL GENETICS Clinical Medical Genetics * Aase, J.M.: Diagnostic Dysmorphology, PlenumMedical, 1990. -a great ‘how-to’ approach to the dysmorphology exam. Easy reading. * Beighton, P.: McKusick’s Heritable Disorders of Connective Tissue, 5th edition, Mosby, 1993. * Emery & Rimoin (eds): Principles and Practices of Medical Genetics, Churchill- Livingston, 1996, Vol I & II, 2nd edition. - Excellent, up-to-date coverage of Medical Genetics including basic principles and specific diseases. * Gorlin, R., Cohen, M.M., Hennekam R.C.M.: Syndromes of the Head and Neck, 4th edition, Oxford Press, 2001. * Gorlin, Toriello, Cohen: Hereditary Hearing Loss and Its Syndromes, Oxford Press, 1995. * King, Rotter, Motulsky: The Genetic Basis of Common Diseases, 2nd edition, Oxford Press, 2002. * Stevenson, Hall, Goodman (ed): Human Malformations and Related Anomalies, Vol I & II, 1993. - Excellent treatise on malformations.
  19. 19. 19 * Milunski (ed): Genetic Disorders and the Fetus: Diagnosis, Prevention & Treatment, 4th edition, Johns Hopkins Press, 1998. * Jones, Kenneth L.: Recognizable Patterns of Human Malformation, W.B. Saunders, 5th edition, 1997. - The “Bible” of syndromes. Clinical handbook of syndromology. Inexpensive and valuable to own. * McKusick, V.A.: Mendelian Inheritance in Man, Catalogues of Autosomal Dominant, Autosomal Recessive and X-Linked Phenotypes, 10th edition, Johns Hopkins Press, 1992. (See OMIM on-line) * Spranger, et al: Bone Dysplasias, An Atlas of Constitutional Disorders of Skeletal Development, 2nd edition, Oxford, 2002. * Taybi and Lachman: Radiology of Syndromes, Metabolic Disorders, and Skeletal Dysplasias, 4th edition, Mosby, 1996. *Wells, R.D. and Warren S.T.: Genetic Instabilities and Hereditary Neurological Diseases, Academic Press, 1998. Basic Genetics * Thompson & Thompson: Genetics in Medicine, W.B. Saunders, 5th edition, 1991. - excellent clinical genetics overview and good book to read cover to cover during rotation. * Jorde, Carey, Bamshad & White: Medical Genetics, 2nd edition, Mosby, 1999. - excellent overview of clinical genetics, easy to read. * Sack, G.H.: Medical Genetics, McGraw Hill, 1999. * Vogel & Motulsky: Human Genetics, Springer-Verlag, 1985, 2nd edition. - comprehensive Human Genetics textbook. * Mange, A.P. & Mange: Human Genetics Aspects, Sinauer Ass., 1990. Cytogenetics *de Grouchy, Jean and Turleau, C.: Clinical Atlas of Human Chromosomes, John Wiley & Sons, 2nd edition, 1984. - Catalog of chromosomal disorders. * Gardner, R.J.M., Sutherland, G.R.: Chromosome Abnormalities and Genetic Counseling, 2nd edition, Oxford Press, 1996. ISCN, An International System for Human Cytogenetic Nomenclature, Cytogenetics and Cell Genetics, 21:6, 1978. Sandberg, A. A.: The Chromosomes in Human Cancer & Leukemia, Elsevier, 2nd edition, 1986. Heim, S., Mitelman, S.: Cancer Cytogenetics, Alan R. Liss, 1987. Thurman, Eva: Human Chromosomes, Structure, Behavior and Effects, Springer-Verlag, 2nd edition, 1986. Embryology *MooreK.L., Persaud, T.V.N.: The Developing Human: Clinically Oriented Embryology, 6th edition, W.B Saunders, 1998. *Sadler T.W.: Langman’s Medical Embryology, 7th edition, 1995.
  20. 20. 20 *Skandalakis, J.E.& Gray, S.W.: Embryology for Surgeons, 2nd edition, Williams & Wilkins, 1994. Metabolic Genetics * Adams & Lyon: Neurology of Hereditary Metabolic Disease of Children, McGraw-Hill & Hemisphere Publishing Corp., 1982. * Ampola: Metabolic Diseases in Pediatric Practice, Little, Brown & Company, 1982. * Scriver, C.R., et al: The Metabolic Basis of Inherited Disease, McGraw-Hill, 7th edition, 2000. Molecular Genetics * Ross, D.W.: Introduction to Molecular Medicine, Springer-Verlag, 1992. * Strachan & Read: Human Molecular Genetics, Wiley-Liss, 1996. - Comprehensive Text Book Counseling * Applebaum & Firestein: A Genetic Counseling Casebook, The Free Press, A Division of MacMillan, Inc., 1983. * Kelly, T.E., Clinical Genetics and Genetic Counseling, Year Book Publishing, 1986.
  21. 21. 21 Journals * American Journal of Medical Genetics * Clinical Genetics * Journal of Medical Genetics * Clinical Dysmorphology * The American Journal of Human Genetics * Molecular and Genetic Medicine * Prenatal Diagnosis * Birth Defects Research (formerly Teratology) Human Genetics Human Heredity Annals of Human Genetics Cytogenetics and Cell Genetics Cancer Genetics and Cytogenetics Human Molecular Genetics * Journal of Autism and Related Disorders Computer Software Ovid Access to Medline, etc. Robin Winter (London) Dysmorphology Database, OMD On-line Mendelian Inheritance in Man: OMIM. * Reprotox Database *In Genetics Library. DO NOT TAKE BOOKS OR JOURNALS OUT OF THE GENETICS LIBRARY ON PENALTY OF REARRANGEMENT OF YOUR DNA. * Additional Medical Genetics Schedules are available at our Web site <<>> Revised: July, 2004 C:DOCUME~1CHPENNYLOCALS~1TEMPOR~1OLK2MEDICA~1.WPD
  22. 22. 22 Hematology/Oncology Rotation Goals and Objectives PGY 2&3 At the end of this rotation the resident should 1. Be able to recognize, evaluate and treat (if necessary) common types of anemia, leukopenia/neutropenia or thrombocytopenia. 2. Be able to recognize bone marrow failure in a patient. 3. Be able to evaluate a patient with a bleeding disorder and screen a patient for a bleeding disorder. 4. Be able to evaluate a patient with a possible malignancy. 5. Be familiar with the common side effects of chemotherapeutic agents. 6. Be able to run a formal tumor board presentation of a new or interesting oncology patient. 7. Know when to refer and be able to co-manage a complicated hematology or oncology patient. Course Description The hematology/oncology rotation is a 4-week rotation involving inpatient and outpatient care. The resident on service should be in the PGY2 or PGY3 years. He/she will participate in all aspects of patient care with the exception of consultations. He/she will follow all inpatients in the hospital, attend the outpatient clinics in the Children’s Blood disorder and Cancer Unit and participate in procedures in clinic and in the OR. He/she will coordinate with the ward teams for coverage on nights and weekends. The supervising attendings are Dr. Chambers, Dr. Gruner, and Dr. Hakami. References 1. Hillman and Clement: Red Cell Manual, current edition 2. Schmaier and Petruzzelli: Hematology for the Medical Student 3. Nathan and Orkin: Nathan and Oski’s Hematology of Infancy and Childhood, 6th edition 4. Pizzo and Poplack: Principles and Practice of Pediatric Oncology, 4th edition 5. Your favorite General Pediatrics text (Rudolph, Nelson, Oski, etc.) 6. The collection of articles in the Heme/Onc conference room
  23. 23. 23 Pediatric Infectious Disease Goals and Objectives: PGY 2 or 3 1. Understand the mechanism or infection, incubation period, and pathophysiology, as well as treatment of the major infections that occur in the pediatric and adolescent population. These include: a. upper respiratory infections b. lower respiratory infections c. sinusitis d. gastrointestinal infections (including viral hepatitis) e. urinary tract infections f. bacterial sepsis g. rickettsial infections h. infectious exanthems i. musculoskeletal infections (including joint space infections and osteomyelitis). j. central nervous system infections (including encephalitis, meningitis, and brain abscess) k. intrauterine and neonatal infections l. HIV m. fever of unknown origin n. tuberculosis and other infections seen in the immigrant population o. sexually transmitted infections p. rare infections seen in travelers (malaria and traveler’s diarrhea, for example) 2. Understand the mechanism of action, spectrum and pharmacokinetics of routine antimicrobial therapy such as penicillins, macrolides, cephalosporins, and vancomycin, etc. Understand the challenges of growing antibiotic resistance. 3. Understand the rationale for immunizations in the pediatric population and the arguments in favor of continuation of this practice. 4. Understand basic immunology and be able to screen for/recognize immunodeficiency states. Course Description: The resident physician elective is available for 2-4 weeks. During this time, they will perform all consults, follow inpatients under care or consultation by the ID attending, and participate in all available ID outpatient clinics. Additional readings and projects are often assigned by the attending physician. Small projects or reports will be decided upon based on the interest of the resident and opportunities provided by patients seen. The resident’s work will be supervised by Dr. Michael Cooperstock. Additional rotators on the ID elective are made by approval with Dr.
  24. 24. 24 Cooperstock, the Chief Resident, and the Program Director. All evaluations will be performed by Dr. Cooperstock. References 1. Feigin and Cherry. Textbook of Pediatric Infectious Diseases, 5th Edition, Saunders, 2004. 2. Long SS, et al. Principles and Practice of Pediatric Infectious Diseases. Churchill- Livingstone, 2003. 3. Remington J, Klein J. Infectious Diseases of the Fetus and Newborn, 5th Edition, Saunders, 2001.
  25. 25. 25 Pediatric Endocrinology (Elective) Updated June 11, 2004 (BB) Goals and Objectives: 1. Provide Residents and Students Approach to Diagnosis and Treatment of Endocrine Disorders. A. Thyroid Disorders-Hypothyroidism/Hyperthyroidism B. Disorders of Growth C. Disorders of Calcium, Phosphate, PTH and Vitamin D D. Disorders of Pubertal Development E. Delayed Puberty F. Turner’s Syndrome G. Obesity H. Autoimmune Endocrinopathies and Multiple Endocrine Neoplasias I. Adrenal Disorders J. Carbohydrate Metabolism and Hypoglycemia K. Genetic Aspects of Endocrine Diseases L. Sexual Differentiation and Ambiguity M. Water Regulation and It’s Disorders 2. Interpreting Endocrine History and Physical A. Interpreting Growth Curves B. Interpreting Bone ages and Endocrine Imaging C. Examining Patient and Interpreting Physical Exam Signs D. Learning Pubertal Tanner Staging E. Reviewing History Pertinent to Endocrine Disorders 3. Understand Type 1 and Type 2 Diabetes as well As MODY and Cystic Fibrosis Diabetes A. Learn How to Manage Diabetic Ketoacidosis B. Learn Various Types of Insulin Regimens C. Learn About Insulin Pumps D. Learn About Managing Chronic Disease with a Team of Nurse Practioners, Social Service and Nutritionists E. Learn how to Diagnose Type 1 vs Type 2 F. Learn about MODY and Cystic Fibrosis Diabetes 4. Conferences A. Combined Adult Endocrine and Pediatric Endocrine Tuesdays 1 PM B. Genetics Journal Club 2nd and 4th Tuesday @ 12:15 PM C. Metabolism Conference 2 PM Thursdays – Dr. Richard Hillman D. Journal Club/Adult Fellow Education- Fridays 8:15 Am E. Combined Pediatric Endocrine/Adolescent Medicine Thursdays 8:15 Am
  26. 26. 26 Course Description: Residents/4th Year Students: Residents and 4th Year Students will be under the guidance of Bert Bachrach, MD. The goal is to provide an exciting learning experience that is enjoyable for both the Attending and Resident/4th Year Student. The expectations are that students participate in the rotation and take as much of an active role in their learning experience. They will be expected to present an oral presentation. The topic is not necessarily Endocrine in nature but a topic agreed upon by both the Attending, Resident or 4th Year Student. Residents and Students will be expected to round on inpatients as well as perform consultations. An Endocrine Textbook can be provided to the student as well as Handouts upon initiating rotation. The goal is to further enhance one’s skills as a primary care provider, specialist or budding Endocrinologist to not only evaluate patients and determine a diagnosis; but to research topics and determine the best course of action in management. References: 1. Pediatric Endocrinology- Radovik/MacGillivary 2. Pediatric Endocrinology and Growth- Wales/Witt/Rogol 3. Williams Textbook of Endocrinology 4. Inborn Metabolic Diseases-Fernandes/Saudubray/ Van den Berghe 5. Wilkins The Diagnosis and Treatment Endocrine Disorders in Childhood and Adolescence- Kappy, Blizzard, and Migeon 6. Gruelich and Pyle Bone age Standards 7. And much much more………….. Questions: If you have any questions regarding this rotation please feel free to contact me or stop by my office. This is a fantastic rotation that is really enjoyable and will enhance your skills as Pediatrician, Family Practicioner, Internist or whatever your chosen career. Sincerely, BB Bert Bachrach, MD Director Pediatric Endocrinology/Diabetes DC058.00, N714 One Hospital Drive Columbia, MO 65212 Tel: 573-882-6979 Email: P.S.: Faint Hearted need not apply for this rotation
  27. 27. 27 Nephrology/Urology (elective) Goals and Objectives: PGY 2 or PGY 3 1. Learn the differential diagnosis and initial evaluation of proteinuria and hematuria by incidence and age group (i.e. nephritic syndrome and nephrotic syndrome). 2. Understand the initial evaluation and cost effective laboratory testing for common renal disorders of nephritic syndrome, orthostatic proteinuria, UTI, hematuria, and renal tubular acidosis. 3. Learn a logical approach to enuresis (nocturnal and diurnal) for diagnosis and management. 4. Recognize and diagnose common nephrologic conditions, such as; common causes of acute and chronic renal failure in children, hemolytic uremic syndrome, hypertension, vesico-ureteral reflux, and hydronephrosis (both prenatal and postnatal). 5. Understand urinalysis results in diagnosis and management of common urologic and nephrologic disorders. 6. Learn the basic principles of fluid and electrolyte management, such as, dehydration, hyponatremia, hyper or hypocalcemia, and uremia. 7. Understand the pathophysiology and management of common systemic conditions that present with renal involvement such as: Henoch-Schonlein Purpura, systemic lupus erythematosus, sickle cell disease, and urinary tract infections. 8. Become familiar with dialysis techniques in children. 9. Become familiar with the more common urologic conditions seen in children: hydrocele, hypospadias, epispadius, varicocele, undescended testis, and scrotal conditions such as epididymitis and testicular torsion. 10. Become knowledgeable about the evaluation of babies born with ambiguous genitalia. Course Description: To provide the resident physician with exposure to kidney disorders affecting children. Patients are seen primarily in an outpatient setting, but residents on this elective are expected to follow inpatient consults and nephrology patients in the consultant role. The resident will also spend time in Pediatric Urology clinic with Dr. Lynn Teague. In the urology section of the rotation the resident will be expected to observe at least 10 common urologic procedures. Most of said procedures will be done Friday mornings. All activities are supervised by Drs. Ted D. Groshong and Lynn Teague. This includes dealing with psychosocial aspects of chronic disease and participating in the team approach to care. Evaluations will be performed by the above attending physicians. References Huner, C.D., Harman, W.E., Niaudet, PI; Pediatric Nephrology, 5th Edition, Lippincott. Williams and Williams, New York, 2004 Several Pediatric Urology texts available for loan by Dr. Teague.
  28. 28. 28
  29. 29. 29 Pediatric Neurology Rotations (required) Welcome to the Pediatric Neurology Rotation!! Pediatric neurology is an exciting field in medicine. It offers interdisciplinary experience in pediatrics, neurology, and developmental neurobiology. We are glad to have a chance to share this experience with you. We hope this rotation will be productive and enjoyable for you. Learning Objectives: In order to make your time and effort worthwhile we have identified the following objectives for your learning during this rotation. We understand that your rotation may be brief and may not be able to cover all areas in one stint but we will try our best to achieve these goals. (1). To understand the dynamics of a developing brain and to identify the consequences of insults and defects occurring in different developmental stages. (2). To be able to take a comprehensive medical history pertinent to the pediatric neurological disorders. (3). To learn to perform neurological examinations in children of different ages. (4). To be able to generate some differential diagnosis after evaluating a child with neurological disorders. (5). To become familiar with some of the diagnostic work-up for the common pediatric neurological disorders. (6). To understand the choice and rationale for the various therapeutic interventions in pediatric neurological disorders. Daily Schedule: (1). The residents are allowed to attend morning reports and continuity clinics in their perspective departments. The residents should inform the attendings of their schedules at the beginning of the rotation. In general, they should report to the clinics or the pediatric neurology attending on service no later that 9:00 AM each day on weekdays. (2). All residents are expected to attend the weekly neurology/neurosurgery grand rounds on Wednesday mornings from 8:15 to 9:15. (3). All residents are expected to participate in the outpatient clinics and inpatient care both on neurology service and on consult service.
  30. 30. 30 Clinic schedules: Dr. Patel has clinics on Monday all day, Tuesday AM, Wednesday PM , and Friday AM. Inpatient Care: The inpatient care is directed by Dr. Patel. Whenever there is no clinic session the team should round with Dr. Patel. Inpatient rounds are conducted daily whenever there are neurology patients on the ward or on consult service that requires continuing attention. The residents may be delegated to evaluate a patient on the consult service or as a new admission to the neurology service. The resident will gather the clinical information and report to the attending on service and then see the patient together with the attending. The neurology team is expected to help the pediatric team to schedule diagnostic tests and to gather results of these tests. Didactic Lectures: In addition to the scheduled lectures and conferences listed above the pediatric neurology attending will conduct didactic lectures on selected topics during opportune times and when rounding with the pediatric ward teams. Reading materials: (1). G. Fenichel: Clinical Pediatric Neurology, A Signs and Symptoms Approach. 4th Edition, 2000. (2). Bruce O. Berg: Principle of Child Neurology. McGraw Hill, 1996. (3). John H. Menkes: Textbook of Child Neurology. Sixth Ed. Williams and Wilkins, 2000. (4). The attendings will hand out supplemental reading materials when appropriate. Evaluation/Expected Performance: We expect that the residents will perform satisfactorily before they pass this rotation. Their performance will be evaluated on the basis of their progress in knowledge acquisition and skills in clinical evaluation of a child. An enthusiastic attitude and willingness to learn is required for this rotation. Reading on the topics related to the clinic and inpatient cases is the best way to learn. The residents are expected to dictate a complete clinic note on all patients they see. They should follow the format used by the attendings and gather all the information before dictation the note. Residents will fill out the history part of the consult form on all neurology consultation requested by other services. The attending will complete the physical examination and the impression/plan sections.
  31. 31. 31 Contact phone #’s: Secretary of Pediatric Neurology: Zinda Cody 882-5779 or 882-1043 Dr. Patel’s pager 441-4761 Pediatric Neurology Nurses: Robin Davenport, RN, BC, PNP 3663 pgr.
  32. 32. 32 Pediatric Cardiology (elective) Goals and Objectives: PGY 2 or 3 1. Become familiar with important elements of the cardiovascular exam in children of all ages. 2. Be able to effectively evaluate children with chest pain and syncope. 3. Understand the pathophysiology and treatment of common arrythymias of childhood, such as supraventricular tachycardia (SVT). 4. Know the appropriate pathophysiology, diagnostic evaluation and treatment of cyanotic and acyanotic congenital heart disease in infants, obstructive left-sided lesions and obstructive right-sided lesions. 5. Become familiar with commonly used cardiac medications in children, understand their pharmacology and recognize their toxic effects. 6. Recognize when to refer patients to a cardiologist 7. Understand how to read and perform a pediatric electrocardiograms (ECG) 8. Learn how and when to obtain an echocardiogram on a patient. Course Description: The resident should participate in all availabe cardiology clinics during their rotation. They will share patients with medical students, cardiac fellows, and other resident rotators during their time. Teaching will be done by reading assignments and by informal talks with Dr. Lababidi, and Dr. Carter. Residents will be expected to perform inpatient consults with the attending cardiologist, as well as, follow inpatient cardiology patients following cardiac catheterization or open-heart surgery. Residents are expected to attend and assist in diagnostic and interventional catheterization procedures. References: Fink BW. Congenital Heart Disease: A deductive Approach to its Diagnosis, 3rd edition. Mosby Yearbook 1991. Moss: Heart diseases in infants, children and adolescents, 5th edition. Behrman: Nelson Textbook of Pediatrics; 15th edition. Oski: Principles and Practice of Pediatrics; 2nd edition. Rudolphs: Rudolphss Fundamentals of Pediatrics; 20th edition. Schamberger MS. Cardiac emergencies in children. Pediatric Annals 1996; 25(6):339-44. Schamburger MS. Cardiac Emergencies. In Tobias JD, ed. Pediatric Critical Care: The Essentials, Futura Publishing, Lababidi Z. Neonatal catheter palliations. In Long, ed: Fetal and Neonatal Cardiology.
  33. 33. 33 Carsons: The Science and Practice of Pediatric Cardiology.
  34. 34. 34 Pediatric Gastroenterology (elective) PGY 2, PGY 3, or PGY 4 (Med Peds) Goals and Objectives 1. Resident will be able to recognize, diagnose and successfully treat GERD in children. 2. Residents will learn how to treat encopresis successfully in the pediatric population. 3. Residents will understand situations in which the rectal examination is important in the diagnostic evaluation. 4. Learn how to evaluate failure to thrive in children. 5. Learn the differential diagnosis and evaluation of hepatitis. 6. Residents will learn how to recognize and treat functional disease, including when referral is necessary. 7. Residents will learn how to screen for and diagnose inflammatory bowel disease (IBD) and understand its pathophysiology, long term complications, and treatment. 8. Learn how to interpret a liver panel appropriately. 9. Learn the differential diagnosis and treatment of diarrhea. 10. Become familiar with the principles and indications for endoscopy in children. 11. Resident may, if he/she wishes, work with Dr. Fleisher to become familiar with the biopsychosocial model of medicine and its application in the treatment of children with recurrent abdominal pain. Course description The resident will spend 4 weeks with the pediatric GI service. He/she will be involved in both inpatient consultations and outpatient clinics. The GI resident will follow GI inpatients in a consulting capacity, but the resident will not be primarily responsible for the patients. When available the resident should attend all endoscopies and outreach clinics. References The GI service will give out appropriate papers and resources on request.
  35. 35. 35 Pediatric Surgery Block (required) PGY 2-PGY3 Goals and Objectives At the end of the rotation the resident should 1. Be proficient in recognizing common pediatric surgical conditions and rationale for the management algorithms. 2. Recognize acute surgical conditions and institute appropriate immediate therapy as needed before definitive surgical intervention. 3. Participate in at least 10 minor and major operations in the operating room. Special focus will be placed on minimally invasive techniques including thoracoscopic and laparoscopic procedures. 4. Become proficient at wound closure, recognizing various tissue planes and understand basic suturing and wound care. 5.Develop an understanding of chronic surgical problems and specific management goals in these patients. Description: This rotation will enable the resident to participate in the preoperative assessment, workup and management of surgical patients. They will also be able to interpret relevant CAT/ Ultrasound scans. Residents will participate or perform central line placements in appropriate patients. They will also participate in assessment of pediatric trauma. References: 1. Principles of Pediatric surgery James O'Neill, Jay Grosfeld, Eric fonkalsrud 2002 2. Pediatric Surgery: Ashcraft et al 2003 3. Operative Pediatric Surgery: by Moritz Zeigler.Richard Azizkhan Thomas Weber. 2004
  36. 36. 36 Pediatric Intensive Care Unit/Post-Operative Care (required) PGY I and 2 Goals and Objectives 1. Recognition of respiratory and hemodynamically compromised patients. Involvement in the resuscitation/stabilization of these critically ill children. 2. Integration of clinical and laboratory data in formulating therapeutic and management plans for critically ill patients. Examples: ventilation management, electrolyte abnormalities, nutrition. 3. Develop an understanding of invasive and non-invasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral, and metabolic functions. 4. Participation in pre- and post-operative management of surgical patients, including identifying the responsibilities of the general pediatrician and intensivist. 5. Evaluation and management of patients following traumatic injury, including head injuries. 6. Gain experience with intubation, peripheral intravenous catheter placement, central line placement, arterial line placement, and chest tube insertion. 7. Communication with child and/or family members regarding status and treatment plan for patient. Involvement with transfers and discharge planning. Participation in discussions with families regarding psychosocial issues and end of life counseling. Course Description: All Pediatric and Med/Peds residents are required to rotate 2 months and 1 month, respectively, in the Pediatric Intensive Care Unit (PICU).(The ward senior will also cover the PICU as a night float.) During the PICU rotation the resident has no direct call requirements in the ICU (though they may have call elsewhere). The resident is expected to follow and assist the intensivist in the care of all patients in the PICU, unless otherwise specified, under the direction of Dr. Downs or Dr. Wankum. This entails collection of patient data, presentations of patient information during rounds, daily notes, and assisting the primary care teams in their care of these sick patients. These patients include both medical and surgical subspecialty patients. Surgical patients include general pediatric surgery, cardiothoracic, neurosurgery, ENT and ortho patients. Requirements by Level of Training There will be an intern and a senior level resident in the PICU for 9 months of the year. When both are present, each will be assigned his own or her own patients. However, the senior level resident will be expected to supervise the intern in the care of his/her group of patients. The senior resident will check that orders are written appropriately and that the proper care plan has been given. Interns will informally present his/her patients to the senior resident on pre- rounds, before both round with the attending physicians. The senior resident will also help the intern, when necessary, to gather data about patients. Both residents will work under the direct supervision of the attending physicians, as noted below.
  37. 37. 37 Currently, Dr. Craig Downs, and Dr. Patricia Wankum are the faculty Pediatric Intensivists and will directly supervise and instruct the rotating resident. Literature searches and in-depth reading will be required on specific patients, in addition to the assigned reading selection. The resident will have access to and encouraged to view video tapes on topics such as Dr. Frost's lecture, "Determining Brain Death," as well as read the section on "Critical Care, end of life, and futility issues" in the Ethics (vol. 1) kept in the Residency Coordinators Office. References: Rogers: Handbook of Pediatric Intensive Care Tobias: Pediatric Pain Handbook Tobias: Pediatric Critical Care: The Essentials
  38. 38. 38 Pulmonology (required) Inpatient Pulmonary Medicine (much of which will be taught on the inpatient ward rotation) 1. Learn and understand the pathophysiology of chronic lung conditions of cystic fibrosis, asthma, pulmonary hemosiderosis, and bronchopulmonary dysplasia. 2. Understand the diagnostic and therapeutic methods of bronchoscopy and thoracocentesis. 3. Learn interventional techniques for management of asthma, hemoptysis, and bronchiolitis. 4. Provide differential diagnosis and evaluation of central and obstructive apnea and other sleep disorders. 5. Participate in the management and coordination of resources with chronically ill patients, working with nursing, social services, dietetians and other health professionals. 6. Obtain an adequate medical and psychological history in complicated pulmonary/allergic patients. 7. Learn the basics of blood gases, acid-base balance. Outpatient Pulmonary Medicine 1. Understand management techniques for outpatient asthma, cystic fibrosis, allergic rhinitis, environmental allergies, sinusitis, bronchiolitis, pneumonia, eczema, food allergies, immune deficiency diseases, and drug allergies. 2. Be able to recognize and diagnose common problems of recurrent respiratory infections, stridor, cough, wheezing and formulate appropriate management plans. 3. Know the pharmacologic mechanisms of commonly used medications for asthma, allergy and cystic fibrosis. 4. Demonstrate and refine the ability to read and utilize diagnostic chest, sinus, and neck radiographs in respiratory disease. 5. Learn to evaluate and diagnose upper airway obstruction such as foreign body, tracheomalacia, vascular ring, and laryngeal web. 6. Adequately interpret spirometry and lung volumes for the diagnosis and management of restrictive and obstructive lung disease in chronic and acute disease states. Learn to interpret skin tests for allergies and other tests for allergic diseases. 7. Recognize the role of upper airway diseases such as allergic rhinitis and sinusitis as aggravating factors of asthma. 8. Learn NIH classification of asthma severity and the appropriate treatment of each group. 9. Learn to interpret the sweat test and other diagnostic tests for cystic fibrosis. 10. Recognize the signs and symptoms of obstructive sleep apnea syndrome. Distinguish the different types of apnea (central versus obstructive) and the various etiologies of each. Know the differential diagnosis for apnea of infancy.
  39. 39. 39 References: 1997 NIH Asthma Management Consensus Statement and 1997 Cystic Fibrosis Consensus Statement Nimmagadda and Evans. Allergy: Etiology and Epidemiology. Pediatrics in Review 1999; 20: 111-115.
  40. 40. 40 Research/Reading Block (elective) PGY 1-4 (Peds-Med Peds) Note: This block can only be taken with permission of the Pediatric or Med-Peds Program Director. Only one block for research/reading may be taken during one’s residency (unless leave is taken which will need to be made up), and it may be taken only if requirements are on track for completion by the end of the resident’s training. Goals and Objectives 1. Help with or complete a research project with a faculty member. 2. Research and write a case report or scientific paper or research and prepare a major talk on a topic in Pediatrics (not including the required Grand Rounds). 3. Read deeply about one or more topics in Pediatrics. If this option is taken a referenced report must be written about at least one of the subjects. Course Description The resident will work with a faculty member advisor on this rotation, who will help by guiding the reading program, or making sure the reading is appropriate for the resident’s needs. If a research project is chosen, the resident will also work with a faculty member who will help plan and execute the research. The faculty advisor will be responsible for evaluating the resident on the rotation. A copy of the completed paper or report should be kept in the resident physician’s file.
  41. 41. 41 Resident Curriculum for Outpatient General Pediatrics Thomas J. Selva, M.D. Associate Professor of Clinical Pediatrics ACUTE-CARE EXPERIENCE: The acute-care experience provides the resident an opportunity to master the evaluation of the acutely ill child in a problem-based setting. In this setting the resident serves as an educational resource to students as well as junior residents in dealing with commonly presenting acute illnesses. During the three years of training, the resident will also develop the skills to serve as a resource for consultation for outside physicians. A board certified general pediatrician currently maintaining an active primary care practice in the same setting will provide supervision of acute-care service delivery. It is in this setting the resident will master the skills necessary to adequately assess and triage patients with acute illnesses, determining whether clinic evaluation is warranted or admission to the hospital for inpatient evaluation and care is necessary. FIRST-YEAR EXPECTATIONS: The first-year resident is expected to serve as the primary care provider in the acute care clinic. During the first-year the resident will acquire the skills necessary to evaluate acutely ill patients and determine an appropriate plan for disposition. The skills for adequately documenting the patient encounter as well as adequately assessing the level of care delivered for appropriate billing will also be mastered. In the latter months of the first-year the resident will develop the skills necessary to manage patient flow in a busy acute care clinic setting. Phone management will be introduced during the first-year and will be supervised an ongoing basis. SECOND-YEAR EXPECTATIONS: The second-year resident will serve as the primary care provider in the acute care clinic as well as an educational resource to junior residents and students. Supervision of student encounters with patients as well as review of student documentation will be included in the resident’s responsibilities. The resident will serve as a resource for managing patient flow through the waiting area and acute care facility. In addition to supervising patient encounters and providing care directly to the patients, the second- year resident will also be responsible for providing educational interludes for the students during low-volume periods. THIRD YEAR EXPECTATIONS: The third year resident will be expected to master the skills necessary for properly assessing and triaging the acutely ill child in an outpatient setting. During rotations in the outpatient acute care clinic, the resident will be expected to serve as an educational resource for junior residents as well
  42. 42. 42 as students, supervising both patient encounters and documentation. During this year the resident will have mastered the skills necessary to properly determine the level of service provided as well as appropriate coding of the patient encounters. The resident will master the skills necessary for managing nursing care as well as scheduling in the outpatient setting. Phone management of patients as well as phone triage will be mastered. At the end of the third year the resident will be capable of managing a busy clinic of acutely ill children in a thorough and efficient manner insuring success in the private or academic sector. PROCEDURES TO BE MASTERED IN THE OUTPATIENT SETTING: 1. Intravenous fluid administration 2. Intravenous access 3. Oral rehydration 4. Simple laceration closure a. Suture closure i. Layered ii. Unlayered b. Tissue adhesive closure 5. Immunization administration 6. Administration of aerosolized medications 7. Splinting techniques a. Upper extremity i. Sugar tong splint ii. Gutter spling iii. Cock-up splint iv. Use of preformed splinting materials b. Lower extremity i. Posterior splint ii. Sugar tong splint iii. Use of preformed splinting materials 8. Closed reduction of dislocations a. Subluxation of the radial head b. Finger dislocations 9. Incision and drainage of simple abscesses 10. Foreign body removal a. Eye b. Ear c. Simple subcutaneous 11. Ear curretage 12. Ear irrigation 13. Tympanometry a. Application of instrument b. Interpretation of results 14. Vision screening
  43. 43. 43 a. Titmus screening b. Auto-refraction 15. Office Audiometry a. Speech thresholds with handheld unit b. Acoustic impedance tympanometry
  44. 44. 44 Resident Curriculum for Outpatient General Pediatrics Continuity Clinic Experience Thomas J. Selva, M.D. Associate Professor of Clinical Pediatrics Continuity Experience: The goal of the continuity experience is to allow residents the opportunity to develop an understanding of and appreciation for the longitudinal nature of general pediatric care. This includes aspects of physical and emotional growth and development, health promotion and disease prevention, management of chronic and acute medical conditions, family and environmental impacts, and practice management. Residents will assume responsibility for the continuing care of a group of patients throughout their training. Inherent in the principal of continuity of care is that patients are seen on a regular and continuing basis, rather than a single occasion. The location where care is delivered will be kept as consistent as possible throughout the resident’s three years of training. The continuity experience will include a setting structured and designed to emulate the practice of General pediatrics and conducive to the efficient processing and management of patients. Residents will devote at least one-half day per week to their continuity experience throughout the three years residency training, and (space permitting) an additional one half-day session per week will be provided to those residents who express interest. This experience will receive priority over other responsibilities, interrupted only for vacations, compliance with resident work hour restrictions per the ACGME, or outside rotations located at too great a distance to allow residents to return. Residents expressing an interest in a primary care career track will be given the option to spend their second half-day of continuity clinic in a primary care setting. Patient populations in the continuity experience will include well patients as well as those with complex and chronic problems. Patients will be recruited by the residents from those managed in the normal newborn nursery, emergency department, inpatient service, intensive care unit (both pediatric and neonatal), specialty clinics, and in other sites where resident training takes place. As a guideline, each half-day experience will include three to six patients per resident in the first- year of training, four to eight patients per half-day in the second-year training and 5 to 10 patients per half-day in the third year training. Semi-annual reviews of resident patient populations will be conducted. Ultimately first-year residents will have built a panel of approximately 50 patients or more by the end of the first-year. Second and third year residents will be expected to maintain a panel of at least 100 patients or more. Each year the resident will be expected to conduct a Quality Assurance review of their patient care using the EQIPP educational modules as a guide. AAP practice guidelines will be used as a standard to measure resident management of selected clinical problems.
  45. 45. 45 The curriculum delineated below emphasizes the generalist approach to common office-based pediatric issues including anticipatory guidance from birth to young adulthood, developmental and behavioral issues, and immunization practices and health promotion, as well as the care of children with chronic conditions. Through this curriculum residents will learn to serve as the coordinator of comprehensive primary care for children with complex and multiple health-related problems and to function is part of a integrated comprehensive health-care system. FIRST-YEAR EXPECTATIONS: With more time allocated for each patient encounter, the first-year resident will acquire the skills necessary to obtain a comprehensive history allowing for the thorough evaluation of the well child. In the first-year the pediatric resident will learn the appropriate milestones used to assess gross motor and fine motor development in the growing child. Anticipatory guidance for all of the well- child evaluations in the first 18 years of life will be mastered. Superb explanation and management of routine childhood immunization schedules will also be mastered. Management of the chronically ill child with multiple medical problems as part of an integrated health care delivery system will be introduced. SECOND-YEAR EXPECTATIONS: Having acquired the skills necessary to obtain a thorough history in the evaluation of the well child, the second-year resident will develop and efficiently manage a larger patient population. Masterful coordination of social as well as medical services will be developed during the second year. Management of the acutely ill child within the limitations of a continuity clinic service, paying special attention to the time constraints of a general clinic will also be mastered. During the second year continuity experience, the concept of office and practice management will be introduced. This will include the management of office staff, nursing staff, supplies, and patient scheduling. THIRD YEAR EXPECTATIONS: The third year resident will maintain at least 5 - 10 patients per half-day session and will stay within scheduling constraints. He or she will serve as a resource to less experienced residents and students. The third year resident will obtain the skills necessary to advance to full-time general practice in an outpatient setting upon finishing the third year. Management of office staff, nursing care, phone triage, and supplies will be mastered by the end of the third year. During the third year the concepts of financial management, risk management, and contract negotiation will be introduced.
  46. 46. 46 Inpatient Pediatrics (required) Goals and Objectives PGY 1 1. Develop an understanding and competence in diagnosis and management of a variety of common pediatric illnesses, severe enough to require in-paitent care. 2. Develop the skills of order writing. 3. Become familiar with an inpatient health care team; including nursing, child life therapy, social services, physical therapy, occupational therapy, consultants and discharge planning. 4. Begin development of skills in recognition and stabilization of ill children. PGY 2 & 3 1. Become adept at determining which patients can be managed in a general inpatient setting and which require more specialized care (i.e. surgical or intensive care). 2. Understand the timing and appropriate utilization of consultants. 3. Be able to develop a complex differential diagnosis and discriminate use of diagnostic testing in the care of ill children. 4. Develop skills of supervision and teaching of students and residents. 5. Become competent in the evaluation, diagnosis, management, and placement into the hospital of ill children. 6. Understand and participate in all psychosocial, medical, and environmental aspects of inpatient care, as well as, discharge planning. Course Description: PGY 1 residents will rotate 4 to 5 months on the in-patient service during their intern year. Med/Ped residents will rotate 2 to 3 blocks during their intern year. The interns will become immersed in the daily care of children with common and interesting conditions that require in- patient care. They will be supervised at all times by a senior resident (PGY 2 or 3) and the attending physician. The intern will follow an average of 6 to 10 inpatients. Call during this block is every 4th night. PGY 2 and 3 residents will rotate 2 to 3 blocks per year (minimum 4 and maximum 6) on the inpatient service. This will be based on the preference of the resident and approval by the Chief Resident and Program Director. The senior resident is responsible for all aspects of patient care on their in-patient service. They are expected to supervise and administer over 1 to 4 interns and 3 to 5 medical students. They are in close communication with the Attending physician at all times. On average, senior residents will be responsible for 15 to 20 patients and do an average of q 4 night call. References: Medical Emergencies I & II - Pediatric Annals 1996. Oski FA, DeAngelis CD, Feigin RD, et al, editors: Principles and Practice of Pediatrics, 2nd edition. Philadelphia: J. B. Lipincott, 1994.
  47. 47. 47 Rudolph AM, Hoffman JIE, Rudolph CD, editors. RudolphRs Pediatrics, 20th edition. Stamford, Connecticut: Appleton and Lange, 1996. Behrman RE, Kliegman RM, Arvin AM, editors: NelsonNs Textbook of Pediatrics, 15th edition. Philadelphia: WB Saunders, 1996. AAP: 2000 Red Book Green: Pediatric Diagnosis: Interpretation of symptoms and signs in children and adolescents; 6th edition. Zitelli: Atlas of Pediatric Physical Diagnosis; 3rd edition. Hurwitz: Clinical Pediatric Dermatology; 2nd edition. Jones: SmithSs Recognizable Patterns of Human Malformations Learning Objectives for Pediatric Wards: To include but not limited too… Fluid and Electrolytes 1) Relate maintenance fluid and electrolyte needs to body weight and metabolic rate. 2) Recognize the differences in mild, moderate and severe deficits among infants compared with children or adults when expressed as percentage of body weight. 3) Describe the indication for a ‘bolus’ and specify the amount and composition. 4) Specify a rehydration plan without the use of a calculator for an infant who has moderate dehydration. 5) List the measures most valuable for monitoring the state of hydration. Reference: Pediatrics in Review, Vol. 22, No. 11, Nov 2001 Respiratory Infections 1) List the most typical bacterial pathogens that cause pneumonia in a newborn infant, list the antibiotics that are appropriate to cover these pathogens and state which antibiotics cover which pathogens, and describe specific CXR findings typical for these pathogens. 2) List the most typical bacterial pathogens that cause pneumonia in a child less than five years of age, the antibiotics that are appropriate to cover these pathogens and describe the CXR findings most typical of these pathogens. 3) List the most typical pathogens that cause pneumonia in a adolescent or adult, ant antibiotics that are appropriate for these pathogens, and the typical CXR findings with each pathogen. 4) List the most typical viral respiratory causes of respiratory distress in young infants and children, the effective treatment strategies and the risks for infants that are admitted to the hospital with RSV, in particular.
  48. 48. 48 5) List the medical problems that make patients more likely to admitted to the hospital with RSV. 6) List the isolation strategies used to prevent transmission of respiratory, contact and nosocomial pathogens. Reference: Respiratory Syncitial Virus and Parainfluenza Virus, NEJM, vol 344:1917-1928, June 21, 2001. No. 25. Acid-Base Disorders 1) Identify the primary disorder 2) Calculate the anion gap. 3) Calculate the excess anion gap. 4) Identify at least five causes of an acute respiratory alkalosis. 5) Identify at least three causes of a chronic respiratory acidosis with metabolic compensation. 6) Identify at least three cause of metabolic alkalosis with respiratory compensation with a low urinary chloride level and normal or high urinary chloride level. 7) Identify at least 7 causes of a metabolic acidosis with respiratory compensation with and without an anion gap. Reference: Haber, R.J. : A practical approach to acid-base disorders. West. J. Med 1991 Aug; 155:146-51. SIDS/ALTE 1) Describe the effects of the ‘Back to Sleep’ campaigns on the incidence of SIDS. 2) Delineate modifiable risk factors of SIDS. 3) Explain the relationship of apnea and SIDS. 4) Delineate recommendations for the prevention of SIDS. 5) Know the most common disorders causing ALTE. Reference: SIDS, ALTE, Apnea and the Use of Home Monitors, PIR, Vol. 23 No. 1, January 2002. Failure to Thrive 1) Plot growth data accurately. 2) Recognize normal and abnormal patterns of growth. 3) Describe the common bases for FTT and the approximate percentages of patients who have these etiologies. 4) Characterize the mainstay of intervention for FTT. 5) Describe the effect of FTT on future development, behavior and cognition. Reference: FTT: An Old Nemesis in the New Millennium, PIR, Vol 21, No. 8 Aug 2000. Pediatric Seizures 1) Define febrile seizures and differentiate between simple and complex febrile seizures. 2) List risk factors for each of the following: development of a fist febrile seizure, recurrence of febrile seizures, and risk of epilepsy in children who have had febrile seizures. 3) Discuss the etiology for febrile seizures in infants and young children.