|
Back to Curriculum Guide
|
|
Skills
Rationale
There are five general skill areas introduced and reinforced during the
pediatric clerkship:
-
Conducting an interview
-
Performing a physical exam
-
Communicating information
-
Identifying and solving clinical problems
-
Developing an initial diagnosis and therapeutic
plan.
These are fundamental competencies and will be taught in some form in all the
third year clerkships. Aspects of these skills that are unique to pediatrics are
identified in the curriculum. The development of competent clinical skills
requires both practice and supervision with feedback.
Learning Objectives
I. Interviewing
-
Patient interviews occur in a variety of clinical settings, including:
initial history for a hospital admission or first ambulatory visit, health
maintenance visit, acute care visit, interim visit for a child with an acute
or chronic health condition. The student should develop an awareness that in
conducting a medical interview in a variety of settings, it is sometimes
appropriate to obtain a complete medical history, while at other times a
more limited, focused or interval history is appropriate. Initially, the
emphasis should be on obtaining complete medical histories. Opportunities to
do more focused work-ups should be available as the student builds
competence.
-
Obtain a medical history from a second party (usually the parent), as well
as from the patient, noting the increased reliability of obtaining
information directly from the patient as the patient matures. The student
must be aware of issues of appropriate privacy at all ages and
confidentiality in older children and adolescents.
-
Obtain a relevant history that is unique to pediatrics in addition to the
standard medical history.
Past History:
-
Neonatal history, including birth weight; approximate gestational age;
maternal complications, such as
extent of prenatal care, infections, exposure to drugs, alcohol or
medications; and problems in the newborn period, such as prematurity,
respiratory distress, jaundice and infections.
-
Immunizations.
-
Development, noting the importance of assessing
developmental milestones in evaluating the health of the child.
-
Diet, noting the importance of assessing the amount, type, and method
of infant feeding.
Family History:
- Number and ages of siblings; consanguinity, known genetic disorders,
early childhood deaths, cardiovascular disease, depression and alcohol
abuse.
Social History:
- Assessment of the home environment, school and peer
relationships.
Review of Systems:
-
Modify the medical history depending on the age of the child,
with particular attention given to the following age groups:
neonate, infant, toddler/preschool-aged child, school-aged child
adolescence.
II. The Physical Examination
-
Establish rapport with children of various ages in order to perform the
physical examination.
-
Recognize that the age of the child influences the areas included in the
exam, as well as the order of the examination, and the approach to the
patient.
-
Recognize the important role of observation as a method of
obtaining data in the assessment of the child.
-
Perform a complete physical examinations on an infant, child and
adolescent, including the observation and documentation of normal physical
findings.
-
Demonstrate the appropriate use of the limited or focused examination,
particularly in the ambulatory setting.
-
Use developmental assessment as part of the physical examination for all
ages.
-
Observe how normal behaviors, such as stranger anxiety, affect the
ability of the examiner to perform the
examination, and develop strategies for improving rapport.
-
Perform the Denver Developmental Screening Test, and know how it is
used to assess motor, language and
social development.
-
Identify the physical changes of puberty and be able to conduct Tanner
staging.
-
Observe and demonstrate physical exam findings unique to
the pediatric age group, and understand how findings have
different clinical significance depending on the age of the child. Some
examples are:
-
Appearance: 1) Recognize signs of acute illness in an
infant, toddler and child by evaluating skin color, respiration,
hydration, mental status, cry and social
interaction. 2) Recognize the importance of observing the psychosocial
condition of the child, including
behavior, development, body habitus (height,
weight, body fat), relationship to parent and examiner, and general
condition.
-
Vital signs: 1) Measure heart rate, respiratory rate, blood pressure
and temperature in an infant and child,
demonstrating knowledge of the appropriate sized blood pressure cuff,
interval to count respirations,
and normal variation in temperature depending
on the route of measurement (oral, rectal, axillary or
tympanic). 2) Understand that normal values of heart
rate, respiratory rate and blood pressure change with age. 3) Recognize
the importance of assessing vital signs in the evaluation of acute
illness.
-
Measurements: 1) Accurately measure height, weight and head
circumference. 2) Plot the data on an
appropriate growth chart. 3) Understand the normal relationships between
height, weight and head
circumference. 4) Recognize the usefulness of longitudinal data.
- HEENT: 1) identify the anterior and posterior fontanels
and assess them for fullness or turgor. 2) Recognize the need for
careful observation of the head size and
shape, symmetry, facial features, ear size and hair whorls as part of
the examination for dysmorphic features. 3) Recognize the red reflex and
strabismus. 4) Assess hydration of the mucous membranes. 5) Examine the
tympanic membranes using pneumatic
otoscopy.
-
Neck: 1) Palpate lymph nodes, know what anatomic areas they drain. 2)
Know that lymph nodes are more
prominent during childhood. 3) Recognize and
demonstrate maneuvers that test for nuchal rigidity.
-
Chest: 1) Recognize how the rate and pattern of
respirations change with age, and that abdominal respirations are normal
in infants. 2) Observe the rate
and effort of breathing as a measure of respiratory distress. 3)
Recognize stridor, wheezing and rales
and be able to distinguish between inspiratory and
expiratory obstruction; and 4) Interpret less serious respiratory
sounds such as transmitted upper airway sounds.
-
Cardiovascular: Palpate pulses in the upper and lower extremities and
auscultate the heart for rhythm, rate,
quality of the heart sounds and murmurs.
-
Abdomen: 1) Understand that the liver edge, spleen tip
and kidneys may be palpable in the normal newborn.
2) Examine the umbilical cord for signs of infection.
3) Examine the abdomen for distention, tenderness,
rebound and mass lesions in an infant or young child with lethargy,
irritability or signs of acute illness,
noting the inability of the patient to communicate
symptoms of abdominal complaints. 4) Be able to do a
rectal examination and recognize when it is indicated.
-
Genitalia: 1) Recognize the appearance of normal
male and female genitalia in the newborn. 2) Recognize
abnormalities, including cryptorchidism, hypospadias, testicular mass in
the male. 3) Be able to examine
the external genitalia of a female patient. 4) Recognize the need for
privacy at all ages.
-
Extremities: 1) Examine the hips of a newborn for
dysplasia. 2) Recognize arthritis. 3) Evaluate gait and
limp.
-
Back: Know how to test for scoliosis.
-
Neurologic examination: 1) Elicit primitive reflexes.
2) Assess tone, gait, strength and reflexes, recognizing the importance
of symmetry. 3) Assess developmental
milestones. 4) Recognize that much of the neurologic
examination of infants and children is accomplished through observation
alone.
-
Skin: 1) Recognize jaundice, petechiae, purpura,
common birth marks (such as nevus flammeus and
Mongolian spots), vesicles, urticaria and common rashes, such as
erythema toxicum, impetigo, eczema,
diaper dermatitis and viral exanthems. 2) Recognize common skin findings
associated with child abuse. 3) Assess skin turgor.
III. Communication Skills
-
Communication with the patient and/or family
-
Establish rapport with the patient and family.
-
Identify the primary concerns of the patient and/or family.
-
Recognize the triangular relationship between physician, patient and
parent and be able to communicate information to both the patient and
parent, making sure both understand the diagnosis and treatment plan and
have the opportunity to ask questions; be aware that the relationship
changes with increasing age of the child.
-
Provide anticipatory guidance during health maintenance visits,
including the newborn nursery visit.
-
Recognize the important role of patient education in management of
acute and chronic illnesses.
-
Written communication skills
-
Write a complete summary of the history and physical examination in a
timely manner which is suitable to place in the patient's chart.
-
Outline the different formats for documenting the history and physical
examination which may be used in different clinical settings.
-
Write admission orders for a hospitalized patient.
-
Write a prescription (see Therapeutics section).
-
Oral communication skills
-
Present a complete, well organized summary of the findings of the
patient's history and physical examination, modifying the presentation
to fit the situation.
-
Communicate effectively with other health care workers, including
consultants, nurses and social workers.
-
Explain the thought process that led to the diagnostic and therapeutic
plan.
-
Use precise descriptions of physical findings and avoid vague terms
and jargon, such as "clear" and "WNL".
IV. Clinical Problem-Solving Skills
-
Develop a complete problem list and a differential diagnosis for each
problem; combine problems where appropriate to develop a differential
diagnosis for the patient's unique combination of symptoms.
-
Use knowledge of key signs and symptoms and the frequency and prevalence
of diseases at different ages when developing a differential diagnosis.
-
Formulate an initial diagnostic and therapeutic plan, considering the
cost, risks, benefits and limitations of laboratory tests, imaging studies,
medications, consultations, hospitalization, and more conservative measures
such as observation.
-
Interpret the results of commonly ordered laboratory tests, such as the
CBC, urinalysis, and serum electrolytes, and recognize that the normal
values of some tests may vary with the age of the patient.
-
Use the pediatric literature to research the diagnosis and management of
clinical problems.
-
Develop critical thinking skills and the ability to use scientific
evidence in making clinical decisions.
- Recognize that physicians work in collaboration with other care providers
in both the medical center and the community, including the schools, Public
Health Department, social service agencies and the Child Protective Service.
V. Procedures
- Understand the indications for procedures such as a lumbar puncture,
parenteral fluids including intravenous and intra-osseous fluids, and
emergency procedures such as intubation. Observe how to provide emotional
support for patients undergoing procedures. Although the technical aspects
of doing procedures should be introduced, there is no expectation of mastery
at the third year student level.
VI. Competencies
-
Evaluate patients from infancy through adolescence in a variety of
clinical settings, establishing rapport with the patient and family in order
to obtain a complete history and physical examination.
-
Prepare a complete written summary of the history and physical and orally
present the case in a focused and chronological manner.
-
Identify clinical problems and outline an initial diagnostic and
therapeutic plan.
-
Know when hospitalization and diagnostic tests are indicated.
-
Select the diagnostic tests which are most likely to be useful and be
aware of their costs and limitations.
-
Effectively communicate information about the diagnosis and treatment to
the patient and caregiver.
-
Obtain up-dated information relevant to the diagnosis and treatment of the
patient, performing a literature search and critical review of the
literature.
|