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Endocrine Outcomes


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Endocrine Outcomes

  1. 1. Goals & Objectives Pediatric Endocrinology I. Rationale: Pediatric Endocrinology represents the study of communication; between distant glands and organs and from cell to cell. Complicated feedback loops are involved in intricate regulation of virtually all body functions through the endocrine system. Thyroid disease, diabetes, short stature and many other conditions can affect the quality of life of children; the general pediatrician needs a working knowledge of pediatric endocrinology principles in order to effectively function on a day-to-day basis. By mastering the principles involved in evaluating a child with a potential endocrine condition and developing a sound knowledge base of endocrinology, the pediatric resident will be prepared to perform well as a general pediatrician in the community after graduation. II. Goal: To acquire and demonstrate the fund of knowledge and practical skills necessary to manage common and complex pediatric endocrine conditions in infants, children, and adolescents. III. Specific Objectives: A. Medical Knowledge 1. GOAL : Normal Versus Abnormal (Endocrine). Demonstrate the ability to differentiate between normal and pathological states related to endocrinology, with the following objectives: a. Describe normal patterns of linear growth and weight gain, applying this to evaluation of variations in growth patterns. b. Describe physiologic events in puberty and Tanner staging, and differentiate normal from early and delayed puberty. c. Differentiate premature thelarche and adrenarche from true precocious puberty. 2. GOAL : Common Conditions Not Referred (Endocrine). Demonstrate the ability to diagnose and manage endocrine conditions generally not requiring referral; with the following objectives: a. Describe the pathophysiology of, recognize, and manage these conditions: i. Abnormal newborn thyroid screen (initial evaluation) ii. Benign premature adrenarche iii. Benign premature thelarche iv. Delayed puberty due to chronic disease or anorexia nervosa v. Exogenous obesity vi. Familial short stature, constitutional delay of growth or puberty vii. Gynecomastia in a pubertal male viii. Infant of mother with gestational diabetes ix. Transient hypocalcemia in a newborn x. Transient hypoglycemia in a newborn 3. GOAL: Conditions Generally Referred (Endocrine). Demonstrate the ability to recognize, initiate management of, and refer endocrine conditions which require referral; with the following objectives: a. Identify, provide initial management of, and refer appropriately these conditions: i. Adrenal insufficiency ii. Ambiguous genitalia, hypogonadism, and micropenis iii. Central and nephrogenic diabetes insipidus and psychogenic polydipsia iv. Congenital adrenal hyperplasia v. Delayed or precocious puberty vi. Diabetes mellitus (diabetic ketoacidosis (DKA), long-term management)
  2. 2. vii. Endocrine and genetic causes of obesity viii. Genetic syndromes and familial inheritance patterns with endocrine abnormalities ix. Hirsutism x. Hypoglycemia in childhood and adolescence xi. Metabolic bone disease including rickets and skeletal dysplasias xii. Persistent abnormalities of calcium, phosphorus, or magnesium homeostasis xiii. Polycystic ovaries and hyperandrogenism in girls xiv. Short stature variants, with selection of possible hormonal treatment xv. Tall stature and excessive growth syndromes xvi. Thyroid dysfunction and goiters xvii. Turner syndrome xviii. Undescended testes xix. Zinc deficiency 4. GOAL: Diabetes Mellitus. Demonstrate understanding of the diagnosis and management of diabetes mellitus; with the following objectives: a. Recognize the initial presentation, perform confirmatory lab tests, treat immediate life threatening complications, and refer for education. b. Order and accurately interpret laboratory tests for screening, confirmation of diagnosis, routine monitoring (glucose and Hemoglobin A1C), and identification of complications. c. Recognize and treat DKA using appropriate IV and PO fluids, insulin, and laboratory parameters. d. Demonstrate understanding of the correct use of home glucose monitoring and adjustment of insulin dosages. e. Describe the use of insulin including initial dosages, adjustment of dosages based on serum glucose records or illness, different preparations, and pharmacokinetics. f. Describe the principles behind preventative, anticipatory care for children with diabetes and their families; be aware of community resources available to the family and diabetic team (camps, American Diabetes Association materials, etc); be aware of future trends for primary prevention of childhood diabetes. g. Monitor patients routinely and review implications of diabetes associated complications (retinopathy, nephropathy, neuropathy). h. Identify the specialist's role in long-term management. i. Counsel patients on the role of diet and exercise. 5. GOAL: Prevention (Endocrine). Demonstrate understanding of the pediatrician's role in preventing morbidity related to endocrine dysfunction in children; with the following objectives: a. Counsel parents and children about changes expected in puberty and normal variations. b. Recognize need for influenza vaccination in children with certain endocrine disorders (hypoadrenalism, diabetes mellitus, hypopituitary, and Cushings Syndrome). c. Counsel asthmatics on steroids about risks. d. Discuss Vitamin D supplements in breast fed infants and select populations with low vitamin D, calcium, or phosphorus intake. B. Skills: Acquire and demonstrate the following skills required to adequately evaluate and manage the common maladies in pediatric endocrinology. 1. Obtain a comprehensive pediatric endocrinology history to include a clear definition of the chief complaint, a comprehensive history of present illness, a thorough past medical history to include a prenatal, perinatal and neonatal history to include birth weight and length, medical history, developmental history, surgical history, dietary history and current medicines expressed as standard dose per Kg or per M2, system review to include symptoms related to the CNS, thyroid and chronic systemic diseases, family history to include age, heights, weights, age of puberty and any medical conditions within the family and to specifically annotate any endocrine maladies; (diabetes, thyroid disease, short
  3. 3. stature, abnormal puberty, infertility, menstrual irregularity, etc), and to summarize relevant previous evaluations. 2. Evaluate and interpret growth data available in the medical record. 3. Perform a thorough physical examination with emphasis on the endocrine system to include but not limited to, accurate measurement of stature/length, assessment of body proportions (upper segment/lower segment ratio, arm span/height) and plotting in the appropriate place on the appropriate growth curve, palpation of the thyroid gland, assessment of sexual maturity rating (Tanner Stage), and comprehensive physical examination related to the chief complaint. 4. Develop a differential diagnosis and plan for laboratory and radiologic evaluation related to the history and physical examination. 5. Interpret laboratory results in the context of the particular patient. 6. Develop an appropriate plan for follow-up. B. Patient Care: Demonstrate a family-centered consistent, compassionate, effective, and age appropriate approach toward the evaluation and management of inpatients and outpatients referred to the pediatric endocrinology service through the above activities. C. Interpersonal Skills and communication: Demonstrate effective communication skills with families and patients referred to the pediatric endocrinology service. Demonstrated effective communication skill during the interaction with nurses and other doctors involved with the referred patient. Maintain comprehensive and concise written consultations and notes on the endocrine patients seen for the service. D. Practiced based learning and improvement: Demonstrate the ability to use the medical literature to effectively and cogently evaluate pediatric endocrine conditions or symptoms and modify management plans appropriately based on the information obtained from the literature. Demonstrate receptiveness to feedback provided during the rotation with appropriate modification of behavior to improve performance. E. Professionalism: Demonstrate a commitment to patient care and learning by timeliness, responsibility for patients seen on the service, and sensitivity to cultural diversity. F. Systems based practice: Demonstrate understanding of cost issues related to pediatric endocrinology lab tests, radiographic studies, and medications. Demonstrate understanding of health care prevention and maintenance related to pediatric endocrinology I. LEARNING ACTIVITIES A. Supplement learning by regularly reading the Pediatric Endocrinology articles provided in the binder loaned to the resident at the beginning of the rotation. This binder contains over 50 articles covering endocrine topics important to the general pediatrician. These topics include: 1. Puberty- advanced and delayed 2. Thyroid disorders 3. Adrenal disorders 4. Growth disorders 5. Diabetes Mellitus 6. Other metabolic syndromes 7. Pituitary disorders A. Patient care experience: 1. Perform initial assessment and plan for consultations written on inpatients referred to pediatric endocrinology. 2. See outpatient endocrine clinic patients with Dr Newman and Dr McClellan, writing the notes on each patient seen. On a usual week this consists of seven ½ day clinics seeing endocrine patients.
  4. 4. A. Meet with Dr Newman and Dr McClellan several times a week for informal discussions and lectures on endocrinology topics. The discussions will focus on learning, in increased depth, about the patients seen on the service. B. At the end of the rotation participate in an oral examination in which you demonstrate competence in evaluation and management of a patient in two or more of the following scenarios: 1. A 16 year old girl with an enlarged thyroid gland 2. A 5 year old male with secondary sexual characteristics 3. A newborn with genital abnormalities 4. A 6 year old female with short stature 5. A 5 day old male with an abnormal newborn thyroid screen 6. A 14 year old female with recurrent diabetic ketoacidosis 7. A 15 year old diabetic with recurrent hypoglycemia 8. A 1 year old male with excessive growth 9. A 17 year old female with amenorrhea 10. A 2 year old male with bowed legs V. EVALUATION A. Throughout the rotation, residents will be evaluated on their ability to gather data, analyze data, and generate differential diagnoses and management plans based upon their reading and experience. Residents should be able to discuss their initial approach, differential diagnosis, evaluation, and management plan for each case encountered during the rotation. B. Mid-rotation evaluation feedback will be given. A written evaluation of the resident’s performance during the rotation will be completed at the conclusion of the experience. Discussion of performance and feedback will be given at the conclusion of the oral examination. V. SUPERVISING STAFF COL Robert J. Newman, MD LTC Donald R. McClellan, MD