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					                St. Barnabas Hospital Department of Pediatrics
                      Continuity Clinic and Outpatient Rotations.
                                 Goals and Objectives
                                  Revised June 2009

During the three years of Continuity Clinic and the Outpatient rotations, the pediatric
resident will develop the knowledge, skills and attitudes necessary for the practice of
general pediatrics in the ambulatory care setting. The Goals and Objectives for the
Continuity Clinic and the Outpatient rotation have been combined primarily because
there is significant overlap between the two rotations. Residents will be scheduled for
Outpatient blocks during each of their three years of training. The Outpatient Goals and
Objectives contains sections for each pediatric subspecialty clinic that the resident may
be assigned to see patients. Residents will not be assigned to all the subspecialty clinics
on each rotation. The aim is that by the completion of training that each resident will
have been exposed to each pediatric subspecialty clinic at least once.

GOAL Continuity Clinic Responsibilities by Year of Training

PL-1
               1.      Develop skills in health supervision visits for all age groups.
               2.      Learn management of common pediatric illnesses.
               3.      Become familiar with normal child development and learn to
                       perform the Denver II.
               4.      Gain familiarity with problems seen by specialists who most
                       commonly receive referrals from primary care pediatricians:
                       Dermatology, ENT, Ophthalmology, Allergy, Gastroenterology.
               5.      Begin to gain necessary skills to deliver phone advice.

PL-2
               1.      Continue to develop clinical competency and efficiency in primary
                       care pediatrics concerning both sick and health supervision visits
               2.      Learn to prioritize problems and develop diagnostic and
                       therapeutic plans for more complex general pediatric problems
                       (encopresis, sexual abuse).
               3.      Develop efficiency skills and increase familiarity with common
                       pediatric illnesses in urgent care clinic.
               4.      Continue to develop necessary skills to deliver phone advice.

PL-3
               1.      Take a supervisory role in working with other residents and with
                       medical students, acting as a team leader.
               2.      Precept the PL-1s and students, review history taking, physical
                       exam skills, and charting.
               3.      Organize and review the lab follow-up of patients.
               4.      Function independently in delivering phone advice.
               5.      Participate in clinic QA/QI project.
              6.      Understand practice management issues, including reimbursement,
                      coding, medical-legal issues involving primary care pediatrics.
              7.      Be prepared for transition into independent practice.


GOAL Broad Educational Guidelines for Residents in Continuity Clinic

   Develop insight into the longitudinal health care needs of children from birth through
      adolescence.

   Understand both normal and abnormal growth and development, age-appropriate
      health maintenance screening, immunization schedules, anticipatory guidance and
      acute illness management.

   Develop the ability to care for medically complex children, to recognize when further
      diagnostic testing or referral is appropriate, and to coordinate the care required.

   Learn about both the procedures frequently performed by generalists and the
      compliance issues associated with CLIA regulations applicable to in-office
      laboratory studies.

   Develop interpersonal skills which foster enhanced communication with patients and
      their parents, colleagues and nursing/clerical staff.

   Acquire practice management skills including the ability to evaluate patients in an
      appropriately organized yet cost-efficient manner.

   Understand the value of quality assurance measures and the medico-legal
      implications of documentation.

GOAL Health Promotion and Screening. Provide comprehensive health care
promotion, screening and disease prevention services to infants, children,
adolescents and their families in the ambulatory setting.

       Perform health promotion (well child care) visits at recommended ages
           based on nationally recognized periodicity schedules (e.g. AAP Health
           Supervision Guidelines, Bright Futures, GAPS).
Perform a family centered health supervision interview.

   1. Define family and identify significant family members and other significant
      caretakers and what role they play in the child’s life
   2. Identify patient and family concerns
   3. Discuss health goals for the visit with the patient and family
   4. Prioritize agenda for the visit with the patient and family
          5. Elicit age appropriate information regarding health, nutrition,
              activities, and health risks
Perform age appropriate developmental surveillance, developmental screening, school
    performance monitoring and job performance monitoring

   1. Identify risks to optimal developmental progress (e.g., prematurity, SES,
      family/genetic conditions, etc.)
   2. Identify patient and parental concerns regarding development, school, and/or
      work.
         3. Perform standardized, validated, accurate developmental screening
         4. tests for infants and children until school age

       Critically observe interactions between the parent and the infant, child, or
           adolescent
       Perform physical exam with special focus on age-dependent concerns and
           patient or family concerns.
       Order or perform and interpret additional age-appropriate screening
          procedures, using nationally recognized periodicity schedules and
          local or state expectations (e.g., newborn screening, lead, hematocrit,
          hemoglobin for sickle cell, blood pressure, cardiovascular risk
          assessment, vision, hearing, dental assessment, reproductive-related
          concerns).
       Order or perform appropriate additional screening procedures based on
          patient and family concerns (e.g. sports involvement, positive family
          history for specific health condition, behavioral concerns, identified
          risk for lead exposure)
       Perform age appropriate immunizations using nationally recognized
           periodicity schedules.
       Provide age-appropriate anticipatory guidance to parent(s) or caregiver(s),
          and child or adolescent, according to recommended guidelines (e.g.,
          AAP TIPP program, Bright Futures, GAPS), on topics including:
              1. Promotion of healthy habits (e.g. physical activity,
              reading, etc.)
              2. Injury and illness prevention.
              3. Nutrition.
              4. Oral Health.
              5. Age appropriate medical care
              6. Promotion of social competence
              7. Promotion of positive interactions between the parent
              and infant/child/adolescent
              8. Promotion of constructive family communication,
              relationships and parental health
              9. Promotion of community interactions
              10. Promotion of responsibility (adolescence)
              11. Promotion of school achievement (middle childhood,
              adolescence)
              12. Sexuality (infancy, early and middle childhood,
              adolescence)
              13. Prevention of substance use/abuse (middle childhood,
              adolescence)
              14. Physical activity and sports
              15. Interpretation of screening procedures
              16. Prevention of violence
       Work collaboratively with professionals in the medical, mental-health,
         educational and community system to optimize preventive health
         services for children.
GOAL: Common Signs and Symptoms Evaluate and manage common signs and
symptoms associated with the practice of pediatrics in the Continuity Clinic and
Pediatric Outpatient Department.
Evaluate and manage the following signs and symptoms that present in the context of
   health care promotion:

   1. Infancy: malpositioning of feet, hip clicks, skin rashes, birthmarks, jitteriness,
      hiccups, sneezes, wheezing, heart murmur, vaginal bleeding and/or discharge,
      foul smelling umbilical cord with/without discharge; undescended testicle, breast
      tissue, breast drainage, malpositioning of feet, malrotation of lower extremities,
      developmental delays, sleep disturbances, difficulty feeding, dysconjugate gaze,
      failure to thrive, frequent infections, abnormal head shape or size, evidence of
      abuse or neglect, abdominal masses, abnormal muscle tone
   2. General: Acute life-threatening event (ALTE), constitutional symptoms,
      excessive crying, failure to thrive, fatigue, fever, weight loss or gain, dental
      caries, excessive thumb-sucking or pacifier use, sleep disturbances, difficult
      behaviors, variations in appetite, variations in toilet training, overactivity, somatic
      complaints, poor school performance, attention problems, fatigue, masturbation,
      anxiety, violence.
   3. Cardiorespiratory: Apnea, chest pain, cough cyanosis, dyspnea, heart murmur,
      hemoptysis, hypertension, inadequate respiratory effort, respiratory failure,
      rhythm disturbance, shortness of breath, stridor, syncope, tachypnea, wheezing.
   4. Dermatologic: Congenital nevus and other birth marks, ecchymoses, edema,
      paleness, petechiae, pigmentary changes, purpura, rashes, urticaria, vascular
      lesions, foul smelling umbilical cord.
   5. EENT: Acute visual changes; dysconjugate gaze; conjunctival injection; ear or
      eye discharge; ear, throat, eye pain, edema, epistaxis; nasal foreign body;
      hoarseness; stridor.
   6. Endocrine: growth disturbance, short stature, heat or cold intolerance, normal and
      abnormal timing of pubertal changes, polydipsia, polyuria.
   7. GI/Nutrition/Fluids: Abdominal pain, mass or distention; ascites; constipation;
       dehydration; diarrhea; dysphagia; encopresis; hematemesis; inadequate intake of
       calories or fluid; jaundice; melena; rectal bleeding; regurgitation; vomiting.
   8. Genitourinary/Renal: Change in urine color, dysuria, edema, enuresis, frequency,
       hematuria, oliguria, pain referable to the urinary tract, scrotal mass, pain or
       edema, trauma to urinary tract or external genitalia, undescended testicle,
       enuresis.
   9. GYN: Asymmetry of breast development, abnormal vaginal bleeding, pelvic or
       genital pain, vaginal discharge or odor; vulvar trauma or erythema, delayed onset
       of menses, missed or irregular periods.
   10. Hematologic/Oncologic: Abnormal bleeding, bruising, hepatosplenomegaly,
       lymphadenopathy, masses, pallor.
   11. Musculoskeletal: Malpositioning of feet, malpositioning of legs, hip clicks,
       abnormal gait, abnormal spine curvature, arthritis or arthralgia, bone and soft
       tissue trauma, limb or joint pain, limp, variations in alignment (e.g., intoeing).
   12. Neurologic: Delays in developmental milestones, ataxia, change in sensorium,
       diplopia, headache, head trauma, hearing concerns, gait disturbance, hypotonia,
       lethargy, seizure, tremor, vertigo, visual disturbance, weakness.
           13. Psychiatric/Psychosocial: Acute psychosis, anxiety, behavioral
                concerns; conversion symptoms, depression, hyperactivity, suicide
                attempt, suspected child abuse or neglect.

GOAL: Common Conditions Recognize and manage common childhood conditions
presenting to the Continuity Clinic and Pediatric Outpatient Department.
Evaluate and manage the common conditions and situations presenting in the context of
   health promotion visits

   1. Infancy: Breast feeding, bottle feeding, colic, congenital hip dislocation,
      constipation, strabismus, colic, parent-infant interactional issues, sleep problems,
      child care decisions, separation protest, stranger anxiety, failure to thrive,
      recurrent respiratory and ear infections, positional foot deformities, rashes,
      teething, injury prevention and safety
   2. General: Colic, failure to thrive, fever, overweight, iron deficiency, lead exposure,
      strabismus, hearing problems, child care decisions, well-child and well adolescent
      care (including anticipatory guidance), parental issues (financial stress, divorce,
      depression, tobacco, alcohol or substance abuse, domestic violence, inadequate
      support networks)
   3. Allergy/Immunology: Allergic rhinitis, angioedema, asthma, food allergies,
      recurrent infections, serum sickness, urticaria.
   4. Cardiovascular: Bacterial endocarditis, cardiomyopathy, congenital heart disease
      (outpatient management of minor illnesses), congestive heart failure, heart
      murmurs, Kawasaki disease, palpitations, rheumatic fever.
   5. Dermatology: abscess, acne, atopic dermatitis, cellulitis and superficial skin
      infections, impetigo, molluscum, tinea infections, viral exanthems, verruca
      vulgaris, other common rashes of childhood and adolescence.
   6. Endocrine/Metabolic: Diabetes mellitus, diabetes insipidis, evaluation for possible
       hypothyroidism, growth failure or delay, gynecomastia, hyperthyroidism,
       precocious or delayed puberty.
   7. GI/Nutritional: Appendicitis, bleeding in stool, constipation, encopresis, foreign
       body ingestion, gastroenteritis, gastroesophageal reflux, hepatitis, inflammatory
       bowel disease, nutritional issues, pancreatitis.
   8. GU/Renal: Electrolyte and acid-base disturbances (mild), enuresis,
       glomerulonephritis, hematuria, Henoch Schonlein purpura, nephrotic syndrome,
       obstructive uropathy, proteinuria, undescended testicles, UTI/pyelonephritis.
   9. Gynecologic: Genital trauma (mild), labial adhesions, pelvic inflammatory
       disease, vaginal discharge or foreign body
   10. Hematology/Oncology: Abdominal and mediastinal mass (initial work up),
       anemia, hemoglobinopathies, leukocytosis, neutropenia, thrombocytopenia.
   11. Infectious Disease: Cellulitis, cervical adenitis, dental abscess with complications,
       initial evaluation and follow-up of serious, deep tissue infections,
       laryngotracheobronchitis, otitis media, periorbital and orbital cellulitis,
       pharyngitis, pneumonia (viral or bacterial), sinusitis, upper respiratory tract
       infections, viral illness, recurrent infections.
   12. Musculoskeletal: Apophysitides, femoral retro- and anteversion, fractures,
       growing pains, hip dysplasia, limp, metatarsus adductus, sprains, strains, tibial
       torsion.
   13. Pharmacology/Toxicology: Common drug poisoning or overdose, ingestion
       avoidance (precautions).
   14. Neurology/Psychiatry: Acute neurologic conditions (initial evaluation),
       behavioral concerns, discipline issues, temper tantrums, biting, developmental
       delay, seizures (evaluation and adjustment of medications), ADHD, learning
       disabilities, substance abuse.
   15. Pulmonary: Asthma, bronchiolitis, croup, epiglottitis, pneumonia; sinusitis,
       tracheitis, viral URI and LRI.
            16. Surgery: Initial evaluation of patients requiring urgent referral, pre-
                and post-op evaluation of surgical patients (general, ENT, ortho,
                urology, neurosurgical, etc.).

GOAL: Diagnostic Testing. Utilize common diagnostic tests and imaging studies
appropriately in the pediatric outpatient department.
      Demonstrate understanding of the common diagnostic tests and imaging
        studies used in the outpatient setting, by being able to:
          Explain the indications for and limitations of each study.
          Know or be able to locate age-appropriate normal ranges (lab
             studies).
          Apply knowledge of diagnostic test properties, including the
             use of sensitivity, specificity, positive predictive value,
             negative predictive value, likelihood ratios, and receiver
             operating characteristic curves, to assess test utility in
             clinical settings.
          Recognize cost and utilization issues.
          Interpret the results in the context of the specific patient.
          Discuss therapeutic options for correction of abnormalities.
Use appropriately the common laboratory studies in the Continuity Clinic and Outpatient
   setting:

   1.  CBC with differential, platelet count, RBC indices.
   2.  Blood chemistries: electrolytes, glucose, calcium, magnesium, phosphate.
   3.  Renal function tests.
   4.  Tests of hepatic function (PT, albumin) and damage (liver enzymes, bilirubin).
   5.  Serologic tests for infection (e.g., hepatitis, HIV).
   6.  CRP, ESR.
   7.  Routine screening tests (e.g., neonatal screens, lead).
   8.  Wet preps and skin scrapings for microscopic examination, including scotch tape
       test for pinworms.
   9. Tests for ova and parasites
   10. Thyroid function tests.
   11. Culture for bacterial, viral, and fungal pathogens, including stool culture.
   12. Urinalysis.
   13. Gram stain.
           14. Developmental and behavioral screening tests.

Use the common imaging, diagnostic or radiographic studies when indicated for patients
   evaluated in Continuity Clinic or the Outpatient Pediatric Clinic:

   1. Plain radiographs of the chest, extremities, abdomen, skull, sinuses.
   2. CT, MRI, angiography, ultrasound, nuclear scans (interpretation not expected)
      and contrast studies when indicated.
   3. Bone age films
   4. Appropriately order and use the electrocardiogram and echocardiogram.
          5. Skin test for tuberculosis

GOAL: Monitoring and Therapeutic Modalities. Understand how to use
physiologic monitoring and special technology in the Continuity Clinic and
Pediatric Outpatient Department, including issues specific to care of the chronically
ill child.
Demonstrate understanding of the monitoring techniques and special treatments
     commonly used in the Continuity Clinic and Pediatric Outpatient Department.

   1. Discuss indications, contraindications and complications.
   2. Demonstrate proper use of technique or treatment for children of varying ages.
         3. Interpret results of monitoring based on method used, age and
             clinical situation.
Appropriately use the monitoring techniques commonly used in the Continuity Clinic and
   Pediatric Outpatient Department:

   1. Cardiac monitoring
   2. Pulse oximetry.
         3. Repeated assessment of temperature, heart rate, respiratory rate,
             blood pressure, as clinically indicated during an office visit.

Use appropriately or be familiar with the following treatments and techniques in the
   Continuity Clinic and Pediatric Outpatient Department:

   1.   Universal precautions.
   2.   Hand washing between patients.
   3.   Isolation techniques.
   4.   Administration of nebulized medication.
   5.   Injury, wound and burn care.
   6.   Oxygen delivery systems.
            7. Intramuscular, subcutaneous and intradermal injections.

        D. Recognize normal and abnormal findings at tracheostomy,
           gastrostomy, or central venous catheter sites, and demonstrate
           appropriate intervention or referral for problems encountered.
Demonstrate skills for assessing and managing pain.

   1. Use age-appropriate pain scales in assessment.
         2. Describe indications for and use of behavioral techniques and
             supportive care, and other non-pharmacologic methods of pain
             control.

GOAL Endocrine. Prevention, Counseling and Screening. Understand the role of
the pediatrician in preventing endocrine dysfunction, and in counseling and
screening individuals at risk for these diseases.

   A. Identify the individual at risk for developing endocrine dysfunction through
      routine endocrine counseling and screening of all patients and parents, addressing:
                  1. Normal variations in growth (including genetic short
                      stature and constitutional growth delay).
                  2. Expected and normal variations in body changes during
                      puberty. Information should be ethnic group specific.
                  3. The importance of vitamin D supplements in breast-fed
                      infants and select populations with low intake of vitamin D,
                      calcium, or phosphorus.
                  4. Diabetic screening for patients with symptoms of polyuria,
                      polydipsia and polyphagia.
                  5. Diabetic, hypercholesterolemia, and hypertriglyceridemia
                      screening for any child who is obese.
                 6. Newborn metabolic screening when appropriate.
   B. Provide preventive counseling to parents and patients with specific endocrine
      conditions about:
                 1. The association of chronic steroid use and decreased bone
                    density.
                 2. The importance of diabetes control for prevention of long
                    term complications such as retinopathy, neuropathy,
                    nephropathy, and gastroparesis.
                 3. The value of support groups and camps available for
                    children with diabetes mellitus.

GOAL Endocrine Normal Versus Abnormal. Differentiate between normal,
physiologic deviations from normal and pathological states related to endocrinology.

   A. Describe the normal developmental patterns of statural growth and weight gain,
      along with normal variations. Describe body proportions that can help to
      differentiate proportionate from disproportionate short stature.
   B. Perform Tanner staging (SMR) and explain the sequential physiologic events
      associated with puberty.
   C. Identify early puberty and differentiate it from premature thelarche and premature
      adrenarche.
   D. Explain the findings on clinical history and examination that suggest a disease of
      endocrine origin and require further evaluation and treatment. Such diseases
      include hypo- and hyper-thyroid states, diabetes mellitus, diabetes insipidus,
      rickets, obesity, delayed or accelerated growth, early or delayed puberty, adrenal
      insufficiency and hyperactivity, and congenital adrenal hyperplasia.
   E. Interpret clinical and laboratory endocrine tests to identify endocrine disease,
      including: bone age, vitamin D, calcium, phosphate and alkaline phosphatase,
      glucose, insulin, and hemoglobin A1C, T4, free T4, TSH, parathyroid hormone,
      serum and urine electrolytes and osmolality, cortisol and ACTH, FSH, LH,
      estradiol, testosterone, cortisol, rennin, adrenal androgens and precursor hormone
      levels, growth hormone, imaging studies (MRI, CT Scan, Ultrasound, and thyroid
      scans) and bone densitometry.

GOAL Endocrine Undifferentiated Signs and Symptoms. Evaluate, treat, and/or
refer patients who present with undifferentiated signs and symptoms that may
represent an endocrine disease process.

   A. Create a strategy for determining if the following presenting signs and symptoms
      are caused by an endocrine disease process and determine if the patient needs
      treatment or referral.
          1. Vomiting/Weight loss
          2. Short and tall stature
          3. Obesity
          4. Polydipsia
          5. Hypoglycemia
          6. Hyperglycemia
          7. Hypocalcemia
          8. Early or delayed puberty
          9. Acanthosis nigricans
          10. Headaches
          11. Dizziness
          12. Diplopia and blurred vision
          13. Polyuria

GOAL Endocrine Common Conditions Not Referred. Diagnose and manage
endocrine conditions in patients not generally requiring referral.

   A. Diagnose, explain the pathophysiology of, and manage the following endocrine
      conditions:
         1. Abnormal newborn metabolic screening, including
             hypothyroidism, congenital adrenal hyperplasia, PKU, and
             galactosemia
         2. Premature adrenarche
         3. Premature thelarche
         4. Delayed puberty due to chronic disease or anorexia nervosa
         5. Exogenous obesity
         6. Familial short stature, constitutional delay of growth or puberty
         7. Short stature variants not meeting criteria for hormone therapy
         8. Gynecomastia in a pubertal male
         9. Infant of mother with gestational diabetes
         10. Transient hypocalcemia of a newborn
         11. Transient hypoglycemia of a newborn

GOAL Endocrine Conditions Generally Referred. Recognize, initiate management
of, and refer patients with endocrine conditions that require referral.

   A. Identify, explain the pathophysiology of, provide initial management for, and
      refer to a subspecialist the following endocrine conditions:
          1. Adrenal insufficiency
          2. Ambiguous genitalia, hypogonadism, and micropenis
          3. Central and nephrogenic diabetes insipidus and psychogenic
              polydipsia
          4. Congenital adrenal hyperplasia
          5. Delayed or precocious puberty
          6. Diabetes mellitus type I (diabetic ketoacidosis (DKA), long-term
              management)
          7. Endocrine and genetic causes of obesity
          8. Genetic syndromes and familial inheritance patterns with
              endocrine abnormalities
          9. Hirsutism, hyperandrogenism, and polycystic ovaries
          10. Hypoglycemia in childhood and adolescence
          11. Metabolic bone disease including rickets and skeletal dysplasias
          12. Abnormalities of calcium, phosphorus, or magnesium homeostasis
          13. Short stature variants meeting criteria for hormonal treatment
          14. Tall stature and excessive growth syndromes
          15. Thyroid dysfunction and goiters
          16. Diabetes mellitus type II
   B. Identify the role and general scope of the practice of endocrinology. Recognize
      situations where children benefit from the skills of specialists trained in the care
      of children, and work effectively with endocrine specialists to care for children
      with endocrinology problems.

GOAL Diabetes Mellitus (Types I and II). Diagnose and manage uncomplicated
diabetes mellitus with or without the assistance of an endocrinologist.

   List the findings on clinical history and examination that suggest a diagnosis of
       diabetes mellitus and/or diabetic ketoacidosis.
   Identify the risk factors for developing type 2 diabetes and provide routine screening
       for those at elevated risk.
   Differentiate Type I and Type II diabetes on the basis of findings from the clinical
       history, physical examination, and laboratory tests.
   Diagnose diabetes mellitus and diabetic ketoacidosis from presenting symptoms and
       confirmatory lab tests.
   Order appropriate confirmatory diagnostic serum and urine tests for diabetes mellitus
       and accurately interpret the results.
   Compare and contrast the different preparations of insulin and describe the
       pharmacokinetics of each.
   Discuss treatment regimens available for patients with Type II diabetes, including the
       use of oral medications, determination of initial dosages, drug pharmacokinetics,
       dose adjustments based on serum glucose levels, possible side effects and
       monitoring for safety.
   Order appropriate initial dosages of insulin based on both clinical and laboratory
       findings and adjust subsequent dosages based on serum glucose levels.
   Order appropriate IV and PO fluids to manage ketoacidosis and initial hyperglycemia
       with or without ketosis, realizing that insulin therapy may be required in the initial
       treatment of Type II diabetes.
   Recognize immediate life threatening complications associated with the diagnosis and
       treatment of diabetic ketoacidosis and steps for initial treatment and stabilization.
       Refer for intensive care as indicated.
   Develop an educational plan for parents and patients that provides effective education
       regarding diabetes, availability of support groups and diabetic camps, diet and
       exercise, home glucose monitoring, adjustment of insulin or oral medications
       dosages, use of insulin pumps, response to illness, and preventive care.
   Develop a cost-effective plan for monitoring patients with diabetes, including use of
       hemoglobin A1-C levels and daily glucose profiles to assess control, frequency
       and severity of hypoglycemia and hyperglycemia, treatment compliance, and the
      development of long term complications such as retinopathy, nephropathy and
      neuropathy.
   Identify the clinical and biochemical indicators that necessitate consultation or
      referral of a child with diabetes.

GOAL Thyroid Disorders. Understand the general pediatrician's role in the
diagnosis and management of patients with congenital and acquired hypothyroidism
and hyperthyroidism.

  A. Explain the findings on clinical history, examination, and laboratory tests that
     suggest the presence of a thyroid disorder (hypo- or hyper-thyroidism), including
     abnormal growth patterns, goiter, etc.
  B. Identify the thyroid function tests, including newborn screening, available for
     detecting and diagnosing a thyroid disorder, and describe the indications for
     ordering, limitations and interpretations.
  C. Discuss the identification, treatment, and follow-up in a patient with congenital
     hypothyroidism. Discussion should include the importance of early detection and
     limitations of newborn screenings, as well as treatment, monitoring and parental
     education.
  D. Identify imaging studies available for patients with a thyroid disorder and the
     indications for obtaining such studies.
  E. Discuss the causes of hyperthyroidism.
  F. Compare and contrast the different treatment options for hyperthyroidism,
     including oral medications, irradiation, and surgery, and discuss the selection
     criteria for each treatment modality.
  G. Create an education, treatment and follow-up plan for a patient with a thyroid
     disorder that includes treatment, monitoring, potential complications, and long-
     term follow-up.
  H. Identify indicators for an endocrine referral of a child with a thyroid disorder.


GOAL Obesity. Understand the general pediatrician's role in the diagnosis and
management of childhood obesity.

  A. Explain the findings on history and physical examination that lead to a diagnosis
     of overweight or obesity in a child or adolescent. These findings should include
     calculation and plotting of body mass index.
  B. Describe medical conditions that either lead to obesity or are caused by obesity
     and identify the steps needed to diagnose and treat such pathologic conditions.
  C. Identify the risk factors for developing obesity, including family history of obesity,
     lack of exercise, sedentary behaviors (such as television viewing and computer
     usage), socioeconomic status, diet of high-calorie food, snacking and other eating
     patterns, and other environmental influences.
  D. Develop an anticipatory guidance plan to counsel patients and families on lifestyle
     changes that may prevent or reduce obesity.
  E. Discuss the adverse health effects associated with obesity. These include the
     relationship of obesity to asthma, type 2 diabetes, gastroesophageal reflux,
     hyperlipidemia, liver disease, hypertension, orthopedic complications,
     psychological effects and stigma, and sleep apnea.
  F. Compare the different methods used to treat obesity, and describe the indications
     for, risks and benefits of the following: diet therapy, physical activity, behavior
     therapy, drug treatment, and surgery.

GOAL Gastroenterology and Nutrition. Prevention, Counseling and Screening.
Understand the role of the pediatrician in preventing gastrointestinal disease or
nutritional deficiencies, and in counseling and screening individuals at risk for these
diseases.

  A. Provide routine gastrointestinal preventive counseling to all parents and patients
     that addresses:

          Good nutrition which includes: breast feeding and age appropriate diet,
             good eating habits, food safety (choking, food preparation, and
             storage), prevention of dietary deficiencies or excesses, prudent
             diet to reduce risks of cardiovascular disease or cancer risk in
             adulthood, and safe methods of weight gain or weight loss.

          Bowel training and dietary prevention of constipation.

          Prevention of Hepatitis A and B through immunization.

          Good hand washing and food preparation techniques for the
             prevention of gastrointestinal infections.

  B. Provide gastroenterology counseling to parents and patients with specific GI
     conditions that addresses:

          Importance of compliance with medications for inflammatory bowel
             and liver disease.

          Need for specialized diets in certain gastroenterology conditions, e.g.,
             IBD, celiac disease, failure to thrive, obesity, lactose intolerance,
             etc.

          Dealing with abdominal pain of apparent psychosomatic origin.

  C. As part of regular GI screening, plot growth parameters using appropriate growth
     charts (e.g., charts for Downs, achondroplasia, Turner, prematurity), and measure
     BMI to monitor trends suggestive of failure to thrive, overweight and obesity.
GOAL Gastroenterology and Nutrition. Normal Versus Abnormal. Differentiate
between normal and pathological states related to gastroenterology.

  A. Describe the normal eating patterns from birth through adolescence, including
     expected weight gain and typical feeding behaviors.
  B. Describe normal developmental patterns in gastrointestinal development, including
     gastro-esophageal reflux, bowel habits, and stool color and consistency.
  C. Explain the findings on clinical history and examination that suggest
     gastrointestinal disease that requires further evaluation and/or treatment. Such
     findings include symptomatic gastro-esophageal reflux, vomiting, diarrhea,
     constipation, abdominal pain, hematemesis, hematochezia, melena, and weight
     loss.
  D. Differentiate transient and functional abdominal pain from pathologic abdominal
     pain.
  E. Discuss the evaluation of liver function and liver abnormalities, and differentiate
     transient elevation of liver enzymes from serious liver disease.

GOAL Gastroenterology and Nutrition. Undifferentiated Signs and Symptoms.
Evaluate, treat, and/or refer patients with presenting signs and symptoms that
suggest a gastrointestinal disease process.

  A. Create a strategy to determine if the following presenting signs and symptoms are
     caused by a gastrointestinal disease process and decide if the patient needs
     treatment or referral.

          Fatigue

          Vomiting

          Growth failure/weight loss/failure to thrive

          Diarrhea

          Constipation

          Abdominal pain

          Jaundice

          Obesity

          Colic

          Chest pain

          Sore throat
  B. Describe the evaluation and management of a child with possible psychosomatic
     abdominal pain.

GOAL Gastroenterology and Nutrition. Common Conditions Not Referred. Diagnose
and manage patients with gastrointestinal conditions generally not requiring
referral.

  A. Diagnose, explain, and manage the following gastrointestinal conditions:

          1. Diarrhea due to infectious causes, including bacterial enteritis,
              giardiasis and viral gastroenteritis
          2. Diarrhea due to non-infectious causes, including chronic
              nonspecific diarrhea, milk protein intolerance, and lactose
              intolerance
          3. Common nutritional deficiencies
          4. Constipation, encopresis
          5. Exogenous obesity
          6. Gastroesophageal reflux
          7. Non-specific intermittent abdominal pain
          8. Irritable bowel syndrome
          9. Jaundice associated with breast feeding
          10. Transient hematemesis due to a Mallory Weiss tear
          11. Viral hepatitis, uncomplicated

GOAL Gastroenterology and Nutrition. Conditions Generally Referred. Recognize
and initiate management of patients with gastrointestinal conditions that generally
require referral.

  A. Identify, explain, provide initial management, and obtain consultation or refer the
     following gastrointestinal conditions:

          Gastrointestinal conditions generally not referred, if severe or
             management is unsuccessful.

          Conditions warranting urgent surgical or gastroenterology evaluation,
             such as: suspected appendicitis, abdominal mass, bowel
             obstruction, volvulus, intussusception, pyloric stenosis, foreign
             bodies lodged in esophagus, caustic ingestions (including watch
             batteries), biliary atresia/stones, congenital GI bleeding, persistent
             hematemesis due to a Mallory Weiss tear and blunt abdominal
             trauma.

          Hepatobiliary diseases, including: neonatal, chronic, or persistent
             hepatitis, direct or conjugated neonatal hyperbilirubinemia or
             hyperbilirubinemia outside the neonatal period; alpha 1 antitrypsin
             deficiency; pancreatitis; and/or hepatosplenomegaly.
           Severe acute or chronic intestinal conditions, including: suspected
              inflammatory bowel disease, colitis, non-infectious gastrointestinal
              bleeding.

           Nutritional deficiencies which are severe or uncommon, including:
              rickets, kwashiorkor, and/or marasmus.

           Chronic diarrhea with or without malabsorption, including: suspected
              celiac disease, cystic fibrosis, Schwachman’s syndrome,
              gastrointestinal infection with prolonged diarrhea, and/or
              undiagnosed diarrhea.

           Gastrointestinal entities requiring special evaluation and follow-up,
              including: morbid obesity, anorexia nervosa, bulimia, severe
              failure to thrive.

   B. Identify the role and general scope of practice of gastroenterology; recognize
      situations where children benefit from the skills of specialists trained in the care
      of children; and work effectively with these professionals to care for children’s
      gastroenterology and nutrition disease processes.

GOAL Vomiting. Diagnose and manage vomiting.

  A. Differentiate normal infant spitting up and functional asymptomatic
     gastroesophageal reflux from vomiting disorders requiring evaluation and
     treatment.
  B. Describe both common and serious disorders leading to vomiting (both intestinal
     and extraintestinal) and the appropriate use of laboratory and imaging studies to
     aid in diagnosis.
  C. Recognize symptoms and urgently refer children with vomiting caused by
     intestinal obstruction.
  D. Describe the typical presentation and suspected course of viral gastroenteritis and
     evaluate vomiting that does not conform to this presentation and course.
  E. Recognize signs and symptoms of dehydration in a child with vomiting. Calculate
     fluid deficits based on weight and clinical symptoms and manage rehydration
     using IV fluids or oral rehydration solutions.
  F. Develop an evidence-based plan, based on etiology, for withholding, feeding or
     reintroducing solid foods during and after vomiting.
  G. Discuss common remedies and medications used to treat vomiting, along with
     indications, limitations and potential adverse effects.
  H. Identify the indicators for a gastroenterology consultation or referral of a child
     with vomiting.
GOAL Abdominal Pain. Diagnose and manage abdominal pain.
   A. Compare the common causes of abdominal pain and describe signs and symptoms
      that differentiate recurrent (functional) abdominal pain of childhood from other
      organic causes that require further evaluation and treatment.
   B. Explain the key components of a complete history and physical examination for
      abdominal pain. These should include pain patterns, weight loss, complete diet
      history, elimination history (including stool size, pattern, and consistency),
      psychosocial history, rectal exam and an age/gender dependent pelvic exam.
   C. Develop a diagnostic and treatment plan for a patient with abdominal pain that
      uses step-wise evaluation and treatment.
   D. Identify indicators that suggest need for a gastroenterology or surgery
      consultation or referral for a child with abdominal pain.
   E. Counsel parents about possible behavioral and psychological sources of
      abdominal pain, and how to handle a child with recurrent psychosomatic pain.

GOAL Diarrhea. Diagnose and manage diarrhea.

   A. Compare and contrast the infectious and non-infectious causes of diarrhea.
      Describe signs and symptoms that differentiate self-limiting diarrhea from
      diarrhea requiring further evaluation and treatment.
   B. Explain the key components of a complete history and physical examination for
      diarrhea, including a complete diet history, length of illness, elimination history
      (including stool size, pattern, and consistency), and travel history, in order to
      classify a diarrheal illness as acute or chronic.
   C. Describe the appropriate diagnostic work up for a patient with acute or chronic
      diarrhea, including factors that suggest celiac disease or cystic fibrosis.
   D. Recognize signs and symptoms of dehydration in a child with diarrhea. Calculate
      fluid deficits based on weight and clinical symptoms and manage rehydration
      using IV fluids or oral rehydration solutions.
   E. Develop an evidence-based plan that is based on etiology for withholding, feeding
      or reintroducing solid foods during and after a diarrheal illness.
   F. Discuss common remedies and medications used for diarrhea, along with
      indications, limitations and potential adverse effects.
   G. Identify the indicators for a gastroenterology consultation or referral of a child
      with diarrhea.
   H. Counsel parents about possible behavioral and psychological causes of diarrhea,
      and explain how to handle a child with recurrent diarrhea of apparent
      psychosomatic origin.

GOAL Gastroenterology and Nutrition. Understand principles of nutrition important
to the general pediatrician.

   A. Conduct an age-appropriate nutritional history and exam for nutritional disorders.
   B. List conditions that may present with malnutrition or which commonly occur in
      combination with malnutrition.
   C. Compare and contrast the major components (e.g., carbohydrate, protein, fat
      sources) of the following milk types: human breast milk, cow's milk-based infant
      formula, soy formula, specialized formulas, and whole milk.
   D. List common signs and symptoms of deficiency in the following nutritional
      components, and identify children at high risk for deficiency. Describe the
      adequate dietary requirements and dietary source for each component.

          1. B12
          2. Calcium
          3. Calorie
          4. Fat
          5. Fluoride
          6. Folate
          7. Iron
          8. Protein
          9. Vitamins A, C, D, K, E
          10. Zinc

   E. Provide informative and accurate nutritional counseling to parents and patients
      suspected of a nutritional deficiency or with exogenous obesity.
   F. Describe intervention approaches with proven efficacy in helping children,
      adolescents and families alter their eating and exercise habits, in order to reduce
      obesity and its attendant lifelong health risks.
   G. Discuss nutritional supplements that can be added to children’s diets to increase
      caloric and nutritional content.
   H. Identify the indicators that would lead you to a nutrition consultation or referral
      for a child with suspected or identified nutritional deficiency and/or exogenous
      obesity.
   I. Identify conditions in which weight alteration may be necessary and provide
      guidelines for safe weight gain or loss.

GOAL Formula Feeding. Perform health promotion related to formula feeding and
manage common problems.

   A. Identify and refer families in need of WIC for assistance.
   B. Assess current use of bottle feeding including:

          1.   How formula is prepared
          2.   How much is offered
          3.   What other liquids are fed through the bottle
          4.   Position of infant during feeds
          5.   Use of bottle-propping
          6.   Breastfeeding

   C. Ascertain family-specific beliefs about bottle feeding and formula including:
       Impact on sleep

       Infant behavior

       Bottles taken to bed

       Use of cereal in bottle

       Relationship of different brands of formula to infant colic, etc.

D. Evaluate whether contraindications exist for feeding standard cow milk-based
   formula.
E. Describe to the family the different types of proprietary formulas, their caloric
   value, and the importance of iron fortification.
F. Discuss the following issues with parents choosing to formula feed:

       1. Formula choice and preparation
       2. Normal feeding patterns including frequency, quantity, burping
          and spitting.
       3. How to recognize signs of hunger and satiety.
       4. Type of bottle to use
       5. Safety issues (e.g., avoid warming bottle in microwave, avoid
          propping bottle, avoid bottles in bed or crib)
       6. Normal patterns of weight loss, weight gain, urine and stool,
          especially in the first several weeks of life.
       7. Recommend and support weaning to cup at appropriate age.
       8. Introduction of solids and reduction of milk intake at appropriate
          age.

G. Recognize and manage the following common problems:

       Significant spitting or emesis of formula

       Excessive stooling or constipation

       Food and formula intolerance or allergy

       Weight loss or poor weight gain

       Excessive weight gain

       Colic

       Infant with poor suck or nippling
GOAL Nutrition (Normal Newborns). Manage breast and bottle feeding in the
newborn period.

   A. Assess a newborn's nutritional status based on maternal medical and obstetrical
      history and infant’s history (e.g., illness, feeding, stools, urination) and physical
      exam (e.g., weight expected for gestational age, subcutaneous fat, hydration,
      neurologic or oral/facial anomalies) and implement appropriate feeding plans.
   B. Counsel parents about feeding choices and assess for potential risks/difficulties.
   C. Encourage and support mothers who are breastfeeding.
   D. Counsel and support mothers who are formula feeding.
   E. Refer mothers to WIC and other resources for assistance with food purchase,
      nutrition education, and breastfeeding support equipment.
   F. Recognize and manage these conditions:

          Common problems for breastfeeding infants and mothers.

          Maternal use of medications that are transmitted via breast milk.

          Maternal infections and risk of transmission (Hepatitis B, Hepatitis C,
             HIV)

          Preserving breastfeeding while managing jaundice.

          Newborn who is a poor feeder.

          Feeding plans for the SGA or premature infant.

          Feeding plans for the infant of a diabetic mother.

          Feeding plans for the infant with a cleft palate.

          Feeding plans for neurologically depressed/abnormal newborn.

GOAL Jaundice. Recognize and manage jaundice in the newborn period.

   A. Interpret maternal history for factors contributing to jaundice (Rh, blood type,
      gestational age, infection, family history of jaundice in infants, etc.).
   B. Interpret infant's history for possible etiologies of jaundice (e.g., infrequent or
      ineffective feeding, poor urine or stool output, acholic stool, blood type, risk
      factors for infection, metabolic disease).
   C. Perform a physical exam to assess for jaundice or other evidence of hepatic
      dysfunction (e.g., skin color, sclerae, bruising, cephalohematoma, organomegaly).
   D. Obtain laboratory tests judiciously for management of the jaundiced infant (blood
      type/Coombs, total, fractionated bili, Hct, peripheral blood smear)
   E. Correctly interpret test results to evaluate jaundice in the clinical setting.
   F. Counsel parents about types of jaundice (physiologic, insufficient breastfeeding,
      breast milk, hemolytic, etc.) and their natural history.
   G. Counsel parents about when to be concerned about jaundice (e.g., icterus beyond
      the face and chest, poor feeding, fever, irritability).
   H. Interpret the significance of a total serum bilirubin level in the context of early
      discharge of newborns, with reference to normative data based on age in hours.
   I. Describe indications for phototherapy and exchange transfusions.
   J. Describe the use of phototherapy in both the hospital and the home and explain
      risks (e.g., dehydration, eye injury, and disruption of breastfeeding routines).
   K. Counsel parents about ways to improve jaundice at home (e.g. frequent feedings,
      exposure to sunlight, etc.)

GOAL Nephrology Prevention, Counseling and Screening. Understand the role of
the pediatrician in preventing renal disease, and in counseling and screening
individuals at risk for these diseases.

   A. Provide routine prevention counseling about kidney health and disease to all
      parents and patients, addressing:

   1. Normal voiding, toilet training, and attainment of bladder control.
   2. Female hygiene.
   3. Urinary tract infections and nonspecificity of physical complaints in infants and
      young children.
   4. Strategies to assure normal bowel and bladder habits.
   5. Importance of routinely measuring blood pressures in children, especially
      overweight children and those with a family history of hypertension.

   B. In conjunction with a specialist, provide specific prevention counseling to parents
      and patients with renal diseases, addressing:

   Importance of continued home and office monitoring in children with specific
      diseases (e.g., blood pressures in children with hypertension or urine protein for
      children with nephrotic syndrome).

   Risks of contact and other sports in children with a single kidney.

   C. Provide routine nephrologic screening

   1. Use blood pressures beginning at age 3 to screen for hypertension, using age and
      height specific BP norms and blood pressure cuffs appropriate for patient’s height
      and weight; discuss criteria for repeat measurements and further evaluation or
      referral.
   2. Obtain and accurately interpret urine for dipstick examination to screen for blood
      and protein at certain milestones (e.g., pre-school and pre-sports examinations).
GOAL Nephrology Normal Versus Abnormal. Differentiate between normal and
pathological states related to the renal system.

   A. Describe age-related changes in blood pressure and normal ranges from birth
      through adolescence.
   B. Differentiate transient or physiological proteinuria and/or orthostatic proteinuria
      from clinically significant (i.e. pathological) persistent or intermittent proteinuria.
   C. Differentiate transient hematuria from clinically significant gross or microscopic
      hematuria.
   D. Explain the findings on clinical history and examination that suggest renal disease
      and require further evaluation and treatment.
   E. Discuss indications for, order and interpret clinical and laboratory tests to identify
      renal disease. Tests should include: urinalysis (dipstick and microscopic), 24 hour
      urine studies, spot urine calcium/creatinine, protein/creatinine and
      albumin/creatinine ratios, serum electrolytes, BUN, creatinine (and methods to
      estimate glomerular filtration rate), calcium, phosphorous, and albumin; complete
      renal ultrasound (kidneys, collecting systems, bladder), intravenous pyelography,
      voiding cystourethrogram (radiographic and radionuclide), renal nuclear scans.

GOAL Nephrology Undifferentiated Signs and Symptoms. Evaluate, treat, and/or
refer patients with presenting signs and symptoms that may indicate a nephrologic
disease process.

   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused by a renal disease process and determine if the patient needs treating,
      consultation, or referral.

   1. Hypertension
   2. Edema
   3. Hematuria
   4. Proteinuria
   5. Growth retardation
   6. Arthritis and arthralgia.
   7. Urinary frequency and/or dysuria
   8. Oliguria
   9. Polyuria and/or polydipsia
   10. Abdominal pain
   11. Abdominal mass
   12. Acidosis
   13. Enuresis
   14. Deteriorating school performance
   15. Nausea, poor appetite, weight loss
   16. Unexpected fractures
   17. Unusual cravings for salt or potassium
GOAL Nephrology Common Conditions Not Referred. Diagnose and manage
patients with common renal conditions who generally do not require referral.

   A. Diagnose, explain, and manage the following renal conditions:

   Urinary tract infection, uncomplicated

   Minor electrolyte disturbances

   Dehydration

   Orthostatic and physiologic proteinuria

   Nonspecific urethritis

   Hypertension, mild

   Nocturnal enuresis

   Urinary frequency without renal cause

   Hematuria without proteinuria, including resolving postinfectious glomerulonephritis

   Henoch-Schonlein purpura without persistent renal involvement

   B. Describe how the primary care of children with chronic kidney disease differs
      from routine primary care, including changes in immunization schedules,
      management of growth, and development, learning and behavioral issues.

GOAL Nephrology Conditions Generally Referred. Recognize, initiate management
of patients with renal conditions who generally require referral.

   A. Identify, explain, initially manage, and refer the following renal conditions:

   1. Acute and chronic renal failure
   2. Hemolytic uremic syndrome
   3. Hypertension, moderate to severe
   4. Renal mass, cyst, hydronephrosis, dysplasia
   5. Diabetes insipidus
   6. Urolithiasis and/or nephrocalcinosis/hypercalcinuria
   7. Tubular defects (e.g., renal tubular acidosis, Fanconi's, Bartter's)
   8. Glomerulonephritis
   9. Nephrotic syndrome
   10. Severe electrolyte imbalance
   11. Abnormal renal function in the acutely ill
   12. Vesicoureteral reflux
   13. Obstructive uropathy
   14. Henoch-Schonlein purpura (persistent renal involvement)
   15. Autoimmune diseases with potential for renal involvement (e.g. systemic lupus
       erythematosus, Wegener, etc.)
   16. Urinary tract infections with vesicoureteral reflux, hypertension, or other renal
       abnormalities
   17. Unexplained hematuria
   18. Proteinuria, other than orthostatic and physiologic

   B. Identify the role and general scope of practice of nephrologists and contrast with
      that of urologists; recognize situations where children benefit from the skills of
      specialists trained in the care of children; and work effectively with these
      professionals to care for children with renal disease.

GOAL Nephrology Urinary Tract Infection. Appropriately manage and refer, when
necessary, patients with urinary tract infections.

   A. Discuss findings on clinical history and examination that lead one to suspect a
      urinary tract infection.
   B. Compare and contrast the different methods of obtaining a urine specimen.
   C. Describe the method for making an appropriate diagnosis of urinary tract
      infection prior to treatment and differentiate between pyelonephritis and cystitis.
   D. Implement appropriate antibiotic treatment of a suspected urinary tract infection
      and list indicators that would result in changes in therapy.
   E. Discuss the appropriate radiologic evaluation for a child presenting with a first
      urinary tract infection, taking into account the age and sex of the child.
   F. Describe indications for antibiotic prophylaxis for recurrent UTI and the long-
      term risks of recurrent UTIs.
   G. Identify indicators for a nephrology or urology consult or referral of a child with a
      urinary tract infection.

GOAL Nephrology Nephrotic Syndrome. Understand the pediatrician's role in the
management of nephrotic syndrome.

   A. Discuss findings on clinical history and physical examination that would lead one
      to suspect nephrotic syndrome.
   B. Discuss the different types of nephrotic syndrome, the current therapies, and the
      need for consistent therapy.
   C. Describe age related differences in the etiology of nephrotic syndrome.
   D. Differentiate between steroid resistant and steroid responsive nephrotic syndrome.
   E. Identify indicators of the need for emergent management and urgent vs. non-
      urgent nephrology referral of a child with nephrotic syndrome.
   F. Along with a nephrologist, provide counseling to parents of children with
      nephrotic syndrome, addressing such issues as risk of infection, venous
      thrombosis, and pulmonary edema, as well as treatment, medication side effects
      and importance of home monitoring.
GOAL Nephrology Systemic Conditions with Renal Involvement. Understand the
pathophysiology and management of common systemic conditions that may present
with renal involvement, and seek consultation or referral appropriately.

   A. Identify and explain the renal involvement seen in the following systemic
      conditions:

   1.   Henoch-Schonlein purpura
   2.   Systemic lupus erythematosus
   3.   Sickle cell anemia
   4.   Bacteremia and sepsis
   5.   Shock
   6.   Dehydration
   7.   Vasculitis
   8.   Diabetes mellitus


GOAL Genetics and Inborn Errors of Metabolism Prevention, Counseling and
Screening. Understand the role of the pediatrician in preventing genetic disease, and
in counseling and screening individuals at risk for these diseases.

   A. Provide routine genetic preventive counseling to all parents and patients that
      addresses:

           1. Disorders identified in the neonatal screening program in one's
              state.
           2. Folic acid supplementation before and during pregnancy.
           3. Early and routine prenatal care and routine genetic screening for
              disease during pregnancy.
           4. Routine screening specific to certain ethnic groups.
           5. Avoidance of known teratogens during pregnancy (e.g. isotretinoin
              and alcohol), and reassurance about most substances which are not
              teratogenic.

   B. Provide prenatal and postnatal genetic preventive counseling to parents and
      patients with specific genetic conditions, addressing:

           1. Genetic disorders with known or presumed inheritance patterns,
              based on a constructed pedigree.
           2. Expected course of known genetic disorders.
           3. Risk factors, including advanced maternal or paternal age and
              previous children with genetic conditions.
           4. Internet and other resources and support groups for known genetic
              disorders.
GOAL Genetics and Inborn Errors of Metabolism Normal Versus Abnormal.
Differentiate disorders in patients associated with genetic predisposition or genetic
disease from normal states or acquired disorders.

   A. Describe general concepts that explain chromosome structure and spontaneous
      mutations, and molecular genetic techniques commonly used in diagnosis of
      genetic diseases.
   B. Describe common patterns of Mendelian vs. non-Mendelian inheritance
      (autosomal dominant and recessive, X-linked, multifactorial, and the effect of
      maternal and paternal age) and demonstrate the ability to construct a pedigree.
   C. Identify common diseases with known inheritance patterns and describe the mode
      of inheritance, including: cystic fibrosis, sickle cell anemia, Marfan syndrome,
      Huntington Disease, neurofibromatosis, and familial cancer syndromes.
   D. Identify common disorders with unusual inheritance patterns and describe the
      mode of inheritance, including: Fragile X, MERRF, and MELAS.
   E. Explain the findings on clinical history and examination that suggest a known or
      potential genetic disorder or inborn error of metabolism.
   F. Perform a thorough physical examination on a child suspected of a specific
      genetic disorder, identifying major and minor congenital anomalies that could be
      signs of an underlying genetic syndrome.
   G. Describe how well child care differs in a child with a genetic condition, e.g., use
      of specific growth charts for specific conditions and physical findings.
   H. Identify appropriate clinical and laboratory tests to help identify genetic diseases
      and inborn errors of metabolism. Explain the reason for the test to a family and
      interpret the results, with the assistance of a geneticist. The tests should include
      the following:
          1. Chromosome analysis (both metaphase and prophase) and FISH
              testing for specific disorders.
          2. Plasma and urine amino acids, urine organic acids, ammonia level,
              venous pH, lactate, pyruvate, and blood acylcarnitine profile.
          3. Molecular testing for Fragile X.
          4. DNA mutational testing for selected disorders.
          5. Newer and future technologies developed for detection of genetic
              disorders (e.g., microarray technology).
   I. Identify written and internet resources to aid in diagnosing a genetic or inborn
      error of metabolism, using physical findings along with laboratory examination.
   J. Discuss the ethical, legal, financial and social issues involved in genetic testing of
      children for genetic disorders that may present in adulthood, testing children for
      carrier status, and providing medical care for patients with known fatal disorders.
   K. Develop strategies to learn about future advances in the understanding of genetic
      disorders, in order to incorporate into one’s practice improved screening,
      identification, counseling and management of such disorders.
   L. Identify the indicators that would lead you to seek a genetics consult.
GOAL Genetics and Inborn Errors of Metabolism Undifferentiated Signs and
Symptoms. Evaluate, treat, and/or refer patients with the presenting signs and
symptoms that suggest a genetic disease process.

   A. Discuss the presenting signs and symptoms for commonly encountered genetic
      disorders (e.g., Trisomy 21, Turner Syndrome, Fragile X, neurofibromatosis,
      spina bifida, Marfan syndrome, achondroplasia) and identify accepted guidelines
      for care.
   B. Develop a management plan for commonly encountered genetic disorders,
      identifying principles of long-term management, including use of disorder-
      specific growth charts and practice guidelines.
   C. Provide primary care for and participate as a team member in medical and
      educational planning for a patient with a genetic disorder.
   D. Identify resources in your community for diagnosis, genetic counseling, therapy,
      and psychosocial support of children with genetic defects and congenital
      anomalies.

GOAL Genetics and Inborn Errors of Metabolism Conditions Requiring Urgent
Referral. Recognize and respond to urgent and/or severe conditions related to
genetics and inherited metabolic disorders.
   A. Identify, explain, provide initial management and support, and seek urgent
       referral for the following genetic and/or metabolic conditions:
           1. Infants presenting with symptoms that indicate the possibility of a
               severe inborn error of metabolism (e.g., metabolic acidosis,
               hyperammonemia, unexplained seizures, ketosis or hypoketosis,
               profound hypoglycemia).
           2. Dysmorphic features found in chromosomal abnormalities that
               require prompt diagnosis in the perinatal period (e.g., Trisomy 13,
               18, 21).
           3. Unexplained critical illness or death suggestive of metabolic
               disorder, requiring collection of tissue samples before or at time of
               death.
           4. Developmental delay with signs or symptoms suggesting an
               underlying metabolic or genetic disorder.
           5. Physiologic changes or regression of milestones that suggest a
               possible metabolic etiology (e.g., urea cycle disorders,
               mitochondrial disorders, lysosomal storage diseases, abnormalities
               of organic/amino metabolism).

GOAL Orthopedics Prevention and Screening. Understand the pediatrician’s role in
preventing and screening for orthopedic injury, disease and dysfunction.

   A. Screen for developmental dysplasia of the hip in the newborn nursery and at
      appropriate health maintenance visits:
         1. Use competent physical examination techniques.
         2. Use radiographs and ultrasonography appropriately.
            3. Educate parents about the rationale for screening and referral.
            4. Refer when indicated.
            5. Introduce parents to the management options that the orthopedist may
                offer.
   B.   Screen for scoliosis on routine examinations (by exam and scoliometer) and refer
        as needed.
   C.   Describe school-based scoliosis screening programs and the benefits and inherent
        limitations of such strategies.
   D.   Screen for occult dysraphism.
   E.   Counsel families regarding risks and prevention of orthopedic injuries sustained
        from play near motor vehicles.
   F.   Advise families about optimal weight and style of backpacks in order to prevent
        back injury.

GOAL Orthopedics Normal versus Abnormal. Differentiate normal variants from
pathologic orthopedic conditions.

   A. Distinguish normal variations in foot, knee and leg development.
   B. Distinguish normal variations in gait and posture.
   C. Order and interpret (with the assistance of the radiologist) common diagnostic
      imaging procedures when evaluating and managing patients with orthopedic
      conditions: plain radiographs, body MRI, CT scan, radionuclide bone scans.

GOAL Orthopedics Undifferentiated Signs and Symptoms. Evaluate and
appropriately treat or refer presenting orthopedic signs and symptoms.
   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused by an orthopedic condition, and if so, treat or refer appropriately:
         1. Limp
         2. Musculoskeletal pain
         3. Refusal to walk or gait disturbance
         4. Refusal to use a limb
         5. Swollen or painful joint
         6. Bowed legs or knock-knees
         7. In-toeing or out-toeing

GOAL Orthopedics Common Conditions not Referred Diagnose and manage
common orthopedic conditions which generally do not require referral to an
orthopedist.

   A. Recognize and manage the following conditions, with appropriate referral for
      physical therapy services for rehabilitation when indicated:

           1.   Clavicular fracture
           2.   Annular ligament subluxation/nursemaid’s elbow
           3.   Elbow medial epicondyle apophysitis/little league elbow
           4.   Erb’s palsy or Klumpke’s palsy
          5. Femoral anteversion and retroversion
          6. Pes planus (flat feet)
          7. Internal and external tibial torsion
          8. Low back strain
          9. Metatarsus adductus
          10. Muscle strains
          11. Non-displaced finger and toe fractures
          12. Tibial tuberosity apophysitis (Osgood-Schlatter disease)
          13. Overuse syndromes
          14. Patellofemoral syndrome
          15. Inversion/eversion ankle sprains
          16. Thrower’s shoulder/epiphysiolysis
          17. Soft tissue contusion
          18. Rotator cuff injury/tendonitis

GOAL Orthopedics Conditions Generally Referred. Recognize, provide initial
management, and refer appropriately conditions that usually require orthopedic
referral.

   A. Recognize, provide initial management of and refer appropriately the following
      conditions:

          1. Avascular necrosis of the femoral head/Legg-Calve-Perthes disease
          2. Signs of child abuse
          3. Cervical spine injury
          4. Compartment syndromes
          5. Talipes equinovarus
          6. Developmental dysplasia of the hip
          7. Fractures and dislocations not listed above, including stress fractures
          8. Knee ligament and meniscal tears or disruptions
          9. Limb length discrepancies
          10. Osteochondritis dissecans
          11. Osteomyelitis
          12. Scoliosis with >20 degree curve
          13. Septic joint
          14. Slipped capital femoral epiphysis
          15. Spondylolysis or spondylolisthesis
          16. Subluxation of the knee or shoulder

   B. Identify the role and general scope of practice of pediatric orthopedists; recognize
      situations where children benefit from the skills of specialists training in care of
      children; and work effectively with these professionals in the care of children
      with orthopedic conditions.

GOAL Orthopedics Therapeutic Procedures. Acquire recommended proficiencies in
orthopedic therapeutic procedures
   A. Develop the expected level of proficiency in the following procedures:

          1.   Immobilization techniques for common fractures and sprains
          2.   Reduction of nursemaid’s elbow
          3.   Cervical spine immobilization
          4.   Reduction of phalangeal dislocation

GOAL Orthopedics Child with a Limp. Understand the evaluation and management
of a child with a limp.

   A. Discuss the evaluation, diagnostic work up, differential diagnosis, and initial
      management of the child with:
         1. Limp
         2. Swollen or painful joint
         3. Refusal to walk
         4. Refusal to use a limb

GOAL Orthopedics Prevention, Counseling and Screening (Sports Medicine).
Understand the pediatrician’s role in preventing sports-related injuries, disorders,
and dysfunction in children and adolescents

   A. Perform a comprehensive pre-participation sports physical examination, including
      screening history, exam, interpretation, record keeping and communication with
      schools about eligibility and limitations.

   B. Counsel patients and families regarding athletic participation, including:
         1. Psychosocial, physical, and health-related value of exercise and sports
            participation
         2. Importance of matching children/adolescents with a suitable sport
         3. Role of physical growth, cognitive growth, and motor development in a
            child’s readiness to participate in sports
         4. Ways to prevent excessive stress and burnout.
         5. Importance of having realistic expectations for a child/adolescent based on
            their developmental status.

   C. Discuss nutrition and body composition with athletes and their families.
   D. Educate patients and families about basic pediatric exercise physiology,
      aerobic/anaerobic exercise, and strength and flexibility training, with special
      emphasis on understanding the effects of puberty on performance.
   E. Counsel patients and families regarding safety equipment (e.g., helmets, eye
      protection, mouth guards, protective cups for adolescent males) and adult
      supervision.
   F. Counsel patients, families and coaches about modifying or discontinuing activities
      in adverse field, playing and weather conditions, and how to prevent heat-related
      illness (dehydration, heat illness, heat stroke).
GOAL Orthopedics Normal versus Abnormal (Sports Medicine). Differentiate
normal physical examination variants from pathological conditions requiring
further evaluation and subspecialty referral

   A. Perform and interpret a musculoskeletal examination with major emphasis on the
      large joints (ankle, knee, hip, back, wrist, elbow, shoulder)
   B. Distinguish a physiologic heart murmur from a pathologic heart murmur.
   C. Identify physical stigmata suggestive of Marfan’s syndrome.
   D. Identify organomegaly (spleen, liver, heart) in determining eligibility for athletic
      participation.
   E. Identify dermatologic conditions that may limit athletic participation (herpes,
      impetigo, tinea corporis, molluscum contagiosum).
   F. Recognize and manage conditions associated with normal physical growth (e.g.
      Osgood-Schlatter disease).
   G. Interpret historical and clinical findings in a manner that allows for selected
      testing and referral, including electrocardiogram, echocardiogram, spirometry,
      imaging studies, orthopedic consultation, physical therapy evaluations, and
      neuropsychological or laboratory testing.
   H. Refer patients with significant medical issues (e.g. single kidney, legally blind in
      one eye) for specialty physician clearance and for appropriate safety gear.
   I. Know which sports are not safe or suitable for children with a given medical
      condition.

GOAL Orthopedics Undifferentiated Signs and Symptoms (Sports Medicine).
Evaluate and appropriately treat or refer sports-related signs and symptoms.
   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused or exacerbated by athletic participation or sports trauma and then treat or
      refer appropriately:

           1. Limp
           2. Musculoskeletal pain
           3. Overuse syndromes
           4. Headaches, post-concussion
           5. Amenorrhea
           6. Near-syncope or syncope
           7. Chest pain
           8. Hematuria
           9. Excessive weight loss
           10. Joint swelling
           11. Wheezing, shortness of breath
           12. Joint instability or laxity

GOAL Orthopedics Injury Management and Rehabilitation (Sports Medicine).
Participate and collaborate with other specialists in the management of sports-
related injuries.
   A. Evaluate and stabilize patients with sports-related injuries on the field, in
      emergency departments, or in the office setting (e.g., fractures, cervical spine
      injuries, sprains, strains, dislocations)
   B. Evaluate, treat and follow-up sports related conditions and injuries, including:
          1. Uncomplicated, acute sports-related injuries (e.g. ankle or finger sprains,
              radial buckle fractures, contusions, hip pointer, turf toe).
          2. Minor overuse conditions (e.g., stress fractures, apophysitis, femoral-
              patella malalignment syndrome or tendonitis).
          3. Acute/chronic medical conditions (e.g. heat stroke, dehydration,
              concussion, asthma, syncope with exercise, female athlete triad).
   C. Recognize sports-related problems that require orthopedic consultation.
   D. Participate in management of the rehabilitation process.
   E. Provide evaluation and stabilization of sports injuries at the scene, including the
      unique considerations of cervical spine injuries and concussions.
   F. Manage and appropriately refer patients with concussions, second-impact
      syndrome, and post-concussive syndrome.
   G. Monitor for overuse syndromes and counsel on strategies for prevention and
      management.
   H. Define sideline and office criteria for return to play after either medical or
      orthopedic injuries (e.g. concussion, heat stroke, ankle sprain, finger dislocation).
      Be familiar with the latest recommendations (AAP, American Heart Association,
      American Academy of Neurologists, American College of Sports Medicine, and
      American Academy of Orthopedic Surgeons).

GOAL Orthopedics Special Issues in Sports Medicine. Coordinate the management
of special issues in pediatric/adolescent patients who participate in athletic activity.

   A. Provide careful management of children/adolescents with chronic medical
      conditions (cystic fibrosis, diabetes, asthma, sickle-cell disease) in order to
      optimize athletic participation.
   B. Advise patients and families about the risks of use and abuse of anabolic steroids
      and other nutritional supplements, including performance-enhancing drugs.
   C. Advise patients and families about the risks of repetitive mild traumatic brain
      injury (MTBI).
   D. Consider unique issues relating to female athletes (e.g. eating disorders,
      amenorrhea, osteoporosis).

GOAL Ophthalmology Prevention, Counseling and Screening . Understand the
pediatrician’s role in preventing ophthalmic disease, injury and dysfunction
through counseling, screening and early intervention.

   A. Counsel patients and families regarding prevention strategies related to the eyes,
      including:
          1. Prophylaxis in the neonatal period for ophthalmia neonatorum
         2. Importance of protective eye wear for sports, chemical splashes,
             ultraviolet light exposure and other activities that warrant eye protection
             (e.g., helmet with cage or face mask, goggles)
         3. Full time eye protection for children with irreversible poor vision in one
             eye
   B. Provide routine screening for visual acuity and eye disorders in the newborn
      nursery, office and school setting. Screen for:
         1. Physical findings (white pupil, etc.)
         2. Visual acuity
         3. Strabismus/amblyopia
   C. Screen for and routinely refer infants with family history of any of the following
      conditions:
         1. Pediatric cataract
         2. Pediatric glaucoma
         3. Retinoblastoma
         4. Strabismus/amblyopia
   D. Screen for and provide routine ophthalmology referral for children with medical
      conditions associated with eye disease, including:
         1. Juvenile rheumatoid arthritis
         2. Extreme low birth weight
         3. Prematurity
         4. Suspected shaken baby syndrome
         5. Severe head trauma

GOAL Ophthalmology Normal versus Abnormal. Differentiate normal from
pathologic eye conditions.

   A. Explain to parents the normal development of visual acuity and visual tracking in
      children.
   B. Distinguish normal or clinically insignificant eye findings from potentially serious
      ones, including:
           1. Variations in pupil size
           2. Variations in eyelid structure
           3. Coloration of the conjunctiva
           4. Coloration of the iris
           5. Appearance of the optic disk
           6. Variation of tearing and minor eye discharge
           7. Pseudostrabismus
           8. Pseudostrabismus vs. strabismus
   C. Demonstrate ability to do a good funduscopic examination on children, using
       mydriatics if needed.
   D. Request or perform and interpret the following clinical studies useful in
       evaluating eye conditions: conjunctival swab for culture and chlamydia FA,
       fluorescein eye exam, radiologic studies of head and orbit, including plain film,
       CT and MRI.
GOAL Ophthalmology Undifferentiated Signs and Symptoms. Evaluate and
appropriately treat or refer commonly presenting ophthalmologic signs and
symptoms.

   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused by an ophthalmologic condition, and if so, then treat or refer
      appropriately:
         1. Red eye (painless or painful)
         2. Strabismus (exotropia, esotropia, pseudoesotropia, lazy eye, crossed eyes)
         3. White light reflex
         4. Scleral pigmentation
         5. Eyelid swelling
         6. Proptosis
         7. Decreased visual acuity
         8. Asymmetric pupillary size or light response
         9. Unequal red reflex
         10. Unequal visual acuity or fixation
         11. Blurry or indistinct optic disc margins (papilledema, optic neuritis)

GOAL Ophthalmology Common Conditions not Referred. Diagnose and manage
patients with common ophthalmologic conditions that generally do not require
referral.

   A. Diagnose and manage the conditions listed below:
         1. Non-herpetic viral and non-gonococcal bacterial conjunctivitis
         2. Corneal abrasion
         3. Periorbital cellulitis
         4. Hordeolum (stye) and chalazion
         5. Simple congenital nasolacrimal duct obstruction in the first year of life
         6. Uncomplicated foreign bodies of the conjunctiva
         7. Minor lid lacerations not involving the lid margin, lacrimal system, or
            ptosis
         8. Small subconjunctival hemorrhage (unless 360 degrees)
         9. Periocular ecchymoses

GOAL Ophthalmology Conditions Generally Referred. Recognize, provide initial
management, and refer appropriately conditions that usually require
ophthalmologic referral.

   A. Recognize, provide initial evaluation and management of, and appropriately refer
      these conditions:
         1. Amblyopia
         2. Cataract
         3. Corneal opacity or edema
         4. Ectopia lentis
         5. Chemical burns/conjunctivitis
         6. Complicated and intraocular foreign bodies
         7. Decreased visual acuity
         8. Sight-threatening ptosis
         9. Strabismus and nystagmus
         10. Glaucoma
         11. Herpetic conjunctivitis/keratitis
         12. Gonococcal conjunctivitis
         13. Uveitis
         14. Red eye and/or corneal ulcer in the contact lens-wearer
         15. Aniridia
         16. Orbital cellulitis
         17. Retinopathy of prematurity in at-risk neonates
         18. Acute infantile dacryocystitis with cellulitis
         19. Significant eye trauma manifested by hyphema, extraocular muscle palsy
         20. Globe penetration, irregular pupil, iritis, or orbital fracture
         21. White, black (absent), or significantly asymmetric pupillary reflex
         22. Congenital malformations of the eye or periocular structures (e.g.
             periorbital hemangiomas)
         23. Orbital tumor (e.g. rhabdomyosarcoma with proptosis)
         24. Papilledema
   B. Discuss the role and scope of practice of optometrists, pediatric and general
      ophthalmologists, and ophthalmology subspecialists (e.g., retina, cataracts);
      describe situations where referral is indicated to an individual with pediatric
      expertise; work effectively with these professionals in the care of children.

GOAL Ophthalmology Recognize various signs of ophthalmologic pathology that
may be manifestations of systemic disorders.

   A. Recognize these signs as potential manifestations of systemic disorders and
      manage and refer when appropriate:
         1. Retinal hemorrhages (e.g. child abuse, leukemia)
         2. Iritis (e.g., juvenile rheumatoid arthritis, inflammatory bowel disease)
         3. Cataracts (e.g., metabolic disorders, genetic malformation syndromes)
         4. Papilledema (e.g., increased intracranial pressure)
         5. Chorioretinitis (e.g., toxoplasmosis, cytomegalovirus)
         6. Subconjunctival hemorrhage (e.g., pertussis, thrombocytopenia, covert
             suffocation)
         7. Periorbital ecchymosis (e.g., neuroblastoma)
         8. Ectopia lentis (e.g., Marfan syndrome, homocystinuria)
         9. Nystagmus (e.g., central nervous system abnormalities, chemical
             poisoning)
         10. Incomplete eye movements (e.g., VI cranial nerve palsy due to increased
             intracranial pressure, metastatic tumor to orbit)
         11. Painful red eye (e.g., endophthalmitis due to sepsis or meningitis, orbital
             involvement of leukemia, thyroid eye disease)
GOAL Ophthalmology Diagnostic and Screening Procedures. Perform diagnostic
and screening procedures associated with pediatric ophthalmology.

   A. Develop proficiency in the following procedures:
         1. Vision screening (acuity and strabismus; color blindness).
         2. Fluorescein dye test to detect corneal abrasion.
         3. Conjunctival swab for bacteria and chlamydia
         4. Removal of simple corneal foreign body.
         5. Contact lens removal
         6. Lid eversion
         7. Funduscopic exam
         8. Eye irrigation
         9. Request and interpret (with the radiologist) results of common imaging
            procedures used in the diagnosis and management of ophthalmologic
            conditions (orbital radiographs, head CT, head MRI).

GOAL Otolaryngology Hearing Loss. Understand the morbidity of hearing loss,
intervention strategies, and the pediatrician's and other specialists’ roles in
prevention, recognition and management.

   A. Understand the epidemiology and prevalence of conductive and sensorineural
      hearing loss in childhood and adolescence.
   B. Recognize the broad impact of hearing impairment on child and family, including
      social, psychological, educational and financial consequences.
   C. Screen for hearing loss, interpret results and counsel parents, including
          1. Family and patient health history
          2. Age-appropriate physical exam
          3. Developmental assessment (behavior, language, speech)
          4. Screening audiology and tympanometry exam
   D. Describe timing and strategies for newborn hearing screening, school and office
      hearing screening.
   E. Recognize thresholds of hearing loss associated with communication difficulties
      in office, school and group settings.
   F. Be familiar with common interventions for hearing impaired children and the age
      at which each should be initiated (e.g., hearing aids, amplification devices,
      cochlear implants, speech training, sign language, lip reading, communication
      devices).
   G. Refer and coordinate school, speech and psychological services for the hearing-
      impaired child as early as possible.

GOAL Otolaryngology Prevention and Counseling. Understand the pediatrician’s
role in preventing otolaryngologic disease and dysfunction through screening and
counseling.

   A. Screen children for hearing loss.
         1. Universal newborn screening and follow-up.
           2. Routine hearing screening at health maintenance visits.
   B.   Screen for speech and language delays and disorders.
   C.   Provide strategies for preventing foreign bodies in nose, airway, and ear.
   D.   Encourage smoking cessation in parents in order to optimize a child’s respiratory
        health.
   E.   Counsel families and adolescents about reducing noise-related hearing loss.

GOAL Otolaryngology Normal versus Abnormal. Differentiate normal
otolaryngologic conditions from abnormal ones

   A. Recognize normal development of the ear, sinuses, nose, pharynx, and of hearing,
      speech, and language from birth to adolescence.
   B. Determine whether a child's otolaryngological dysfunction (e.g., hoarse voice,
      nasal discharge) is a temporary state caused by a minor problem or represents a
      potentially serious pathological process.
   C. Demonstrate ability to perform and/or interpret the following clinical studies or
      procedures
         1. Cerumen removal from ear canal
         2. Simple foreign body removal from nose and ear
         3. Pneumatic otoscopy
         4. Suctioning of nares, oropharynx
         5. Nasopharyngeal wash specimens (collection and interpretation)
         6. Head CT
         7. Sinus, airway radiographs
         8. Airway fluoroscopy
         9. Tympanocentesis

GOAL Otolaryngology Undifferentiated Signs and Symptoms. Evaluate and
appropriately treat or refer these presenting otolaryngological signs and symptoms.

   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused by an otolaryngologic condition, and then treat or refer appropriately:

           1.   Ear pain/drainage
           2.   Nasal discharge
           3.   Snoring
           4.   Sore throat
           5.   Stridor
           6.   Nasal polyps
           7.   Neck mass or anomaly
           8.   Hoarse voice
           9.   Nosebleed

GOAL Otolaryngology Common Conditions not Referred. Diagnose and manage
common otolaryngological conditions that generally do not require referral.
   A. Diagnose and manage these conditions:
         1. Allergic rhinitis
         2. Blunt nasal trauma
         3. Cervical adenitis
         4. Epistaxis
         5. Otitis media and externa, uncomplicated
         6. Parotitis (mild)
         7. Pharyngitis (viral and streptococcal)
         8. Simple nasal and ear canal foreign bodies
         9. Sinusitis
         10. Stridor, mild (Croup, laryngomalacia)
         11. Tonsillar hypertrophy without obstruction
         12. Uvulitis

GOAL Otolaryngology Conditions Generally Referred. Recognize, provide initial
management and refer appropriately conditions that usually require
otolaryngologic referral.

   A. Diagnose, provide initial management of, and refer appropriately conditions such
      as:
          1. Abscess (retropharyngeal, peritonsillar)
          2. Airway obstruction (acute, chronic, tonsillar, adenoidal, nasal, and lower
              airway)
          3. Cholesteatoma
          4. Congenital anomalies of the pinna, nose, lip, palate, jaw, neck
          5. Complicated otitis media, sinusitis, epistaxis, and parotitis
          6. Epiglottitis
          7. Facial nerve palsy
          8. Foreign body of the aerodigestive tract
          9. Head and neck masses
          10. Nasal polyp
          11. Significant hearing loss
          12. Significant trauma to the middle or external ear, nose, lip, palate, pharynx
          13. Sleep apnea
          14. Tympanic membrane perforation (traumatic or persistent)
   B. Identify the role and general scope of practice of the otolaryngologist; recognize
      situations where children benefit from the skills of pediatric specialists; and work
      effectively with these professionals in the care of children.

GOAL Otolaryngology Otitis Media. Diagnose and manage acute and chronic
suppurative otitis media and otitis media with effusion.

   A. Demonstrate successful removal of cerumen from ear canals to achieve
      satisfactory visualization of the TM's.
   B. Describe an optimal means of holding the child and the optimal equipment
      necessary for visualization of the TM in an infant, including type of speculum,
        light source, type of bulb, type of examination head, and use of the bulb to
        observe for TM mobility.
   C.   Demonstrate correct interpretation of the tympanogram for a child with: AOM,
        middle ear effusion, obstruction of the ear canal, ossicular disruption, and
        perforation of the TM.
   D.   Differentiate between complicated and uncomplicated AOM, mild and severe
        AOM, and the appropriate management of each variety.
   E.   Diagnose acute otitis media, using visual and pneumatic otoscopy,
        tympanometry, history, and signs and symptoms (e.g., fever, ear pain).
   F.   Diagnose and treat persistent otitis media, identifying treatment options, including
        indications for tympanocentesis.
   G.   Use antibiotic therapy judiciously to treat acute otitis media, taking into account
        the typical pathogens involved, and their antibiotic sensitivities and resistance
        patterns. Be prepared to explain to parents the need to limit antibiotic use in cases
        of mild illness.
   H.   Explain the role of antibiotic prophylaxis for recurrent acute otitis media.
   I.   Follow-up children with acute otitis media at appropriate intervals, monitoring for
        the development of chronic or recurrent acute otitis media or persistent otitis
        media with effusion.
   J.   Monitor infants and children with chronic middle ear effusion, recurrent acute
        otitis media or chronic otitis media for hearing loss and language delay; recognize
        indications for referral for formal audiologic and speech evaluation.
   K.   Describe the generally accepted criteria for insertion of pressure equalizing tubes
        (PET) in children, with specific reference to published guidelines.
   L.   Recognize clinical cases warranting referral to an otolaryngologist for evaluation
        of need for pressure equalizing tubes (PET) for middle ear ventilation. Refer
        appropriately, providing medical information about medical course under your
        care and special circumstances that may affect the decision.
   M.   Counsel families regarding the risks and benefits of pressure equalizing tubes
        (PET).
   N.   Describe the means of preventing acute otitis media for which there is evidence in
        the literature.

GOAL Otolaryngology Tonsillar and Adenoidal Hypertrophy. Screen, diagnose and
manage patients with symptoms secondary to tonsillar and adenoidal hypertrophy,
and refer when appropriate.

   A. Screen for tonsillar and adenoidal hypertrophy at health maintenance visits, using
      information from the physical examination and history.
   B. Counsel parents about the pathophysiology of conditions associated with tonsillar
      and adenoidal hypertrophy and the possibility of normal developmental
      regression in some cases.
   C. Explain to parents the reasons for referral to otolaryngology and general issues
      related to surgical intervention.
   D. Describe the use of diagnostic tests for assessing tonsils and adenoids (e.g. airway
      films, sleep studies).
GOAL Surgery Normal Versus Abnormal. Differentiate normal conditions from
pathologic ones requiring surgical intervention.

   A. Counsel parents regarding the natural history of uncomplicated umbilical hernia.
   B. Distinguish inguinal hernia from hydrocele and describe when it is appropriate for
      the pediatrician to observe and follow, and when to refer for evaluation.
   C. Distinguish acute abdominal pain related to transient events like constipation,
      musculo-skeletal pain or gastroenteritis from pain that is likely to come from a
      serious surgical condition.
   D. Interpret clinical and laboratory tests to identify conditions that require surgical
      intervention. Tests include blood studies (CBC, ESR, Electrolytes, BUN,
      Creatinine, LFTs, amylase, lipase); occult blood in gastric fluid and stool;
      cultures (blood, stool, wound, urine, fluid from body cavities and abscesses);
      radiographic studies ( KUB and upright abdominal films, barium enema, UGI and
      small bowel follow through).

GOAL Surgery Undifferentiated Signs and Symptoms. Evaluate and appropriately
treat or refer signs and symptoms that may require surgery.

   A. Create a strategy to determine if the following presenting signs and symptoms are
      caused by a surgical condition, provide initial evaluation or treatment, and refer
      appropriately:
         1. Acute abdominal pain
         2. Acute scrotum
         3. Vomiting, especially bilious or bloody
         4. Inguinal swelling or mass
         5. Abdominal mass
         6. Bloody stools

GOAL Surgery Common Conditions Not Referred. Diagnose and manage common
conditions which generally do not require surgical referral.

   A. Diagnose, manage, and counsel patients and parents about the following
      conditions that generally do not require surgical evaluation:
         1. Umbilical hernia
         2. Retractile testes
         3. Resolving hydrocele
         4. Transient lymphadenopathy
         5. Minor lacerations

Conditions Generally Referred (Surgery). Diagnose, provide initial stabilization,
and refer appropriately conditions that usually require surgical evaluation.

   A. Recognize, stabilize, and initiate management and surgical referral for the
      following conditions:
          1.  Intussusception
          2.  Tumor
          3.  Trauma (e.g., blunt abdominal trauma)
          4.  Burns
          5.  Failure to thrive or gastroesophageal reflux requiring gastrostomy tube or
              Nissen fundoplication
          6. Prenatal diagnosis of surgical condition (Congenital diaphragmatic hernia,
              Hirschsprung’s, Atresia or stenosis of gastrointestinal tract, CCAM [cystic
              adenomatoid malformation], abdominal wall defects (gastroschisis and
              omphalocele), lymphatic malformations (cystic hygroma) of the neck,
              esophageal anomalies, sacrococcygeal teratomas)
          7. Caustic strictures of esophagus
          8. Pleural effusion or empyema
          9. Hypertrophic pyloric stenosis
          10. Meconium ileus
          11. Meckel’s diverticulum
          12. Malrotation/volvulus
          13. Neck masses (thyroglossal duct cyst, branchial cleft cyst, cystic hygromas)
          14. Anorectal anomalies (imperforate anus)
          15. Chest wall defects--pectus excavatum and carinatum
          16. Intersex and ambiguous genitalia
          17. Lymphangiomas
          18. Dysphagia – achalasia
          19. Abdominal mass--Wilms Tumor, Neuroblastoma
          20. Ovarian mass--teratomas, etc.
          21. GI Bleeding
          22. Intestinal obstruction
          23. Undescended testis
          24. Ganglion cysts
          25. Inflammatory bowel disease
          26. Polyposis syndromes
          27. Appendicitis
          28. Biliary atresia
          29. Gall bladder disease
          30. Pancreatitis
          31. Vascular anomalies
          32. Identify the role and general scope of practice of pediatric surgeons;
              recognize situations where children benefit from the skills of surgeons
              with specialized training in the care of infants and children; and work
              effectively with these professionals in the care of children’s surgical
              conditions.

GOAL Surgery Appendicitis. Recognize, diagnose, manage and refer patients with
appendicitis.
   A. Recognize common and unusual presenting signs and symptoms indicating
      appendicitis, and diagnose by eliciting the appropriate history and physical
      examination findings.
   B. When the diagnosis is not certain, recognize situations warranting inpatient
      admission for medical observation and repeated surgical consultation during
      course of illness.
   C. Use imaging studies appropriately in the diagnosis of appendicitis.
   D. Obtain laboratory tests suitable for evaluation of appendicitis and also in
      anticipation of surgical intervention.
   E. Discuss potential surgical intervention with patients and families.

GOAL Dental Prevention. Recognize the pediatrician's role in preventing dental
disease and its complications through office-based counseling, screening and early
intervention.

   A. Counsel parents as part of health maintenance visits and as need arises, regarding:

          1. Infant oral care
          2. Prevention of early childhood caries (ECC)
          3. Routine preventive oral health care (brushing, flossing, use of sealants,
              dental radiographs)
          4. Timing of first dental visit
          5. Establishment of a dental home and coordination of care with the medical
              home
          6. "High-risk" vs. "low-risk" diet in caries prevention
          7. Guidelines for fluoride therapy
          8. Use of mouthguards in contact sports
          9. Oral health and systemic implications of intraoral and perioral piercing
          10. Oral health related to chewing tobacco
          11. Special considerations in oral health care for children with mental
              retardation and other special needs
          12. Prophylaxis for subacute bacterial endocarditis
          13. Emergency dental procedures (re-implantation, tooth transport, etc.

   B. Discuss how to use and improve public health strategies and community
      services to enhance oral health education and dental services for children
      in your practice.


GOAL Dental.Normal vs. Abnormal. Differentiate normal variations from
pathological states in oral structures and perform pediatric office screening.
   A. Explain to parents and patients the normal pattern of tooth eruption and
      exfoliation.
   B. Describe variations in tooth development (primary and secondary).
   C. Recognize normal variations in the appearance of the soft tissues of the
      mouth (gingiva, tongue, palate, uvula).
   D. Perform office dental screening during health maintenance visits and refer as
      indicated:

          1. Obtain history for genetic risks, dietary risk, oral habits.
          2. Assess fluoride content in drinking water.
          3. Examine for gum disease, enamel defects and stains, cavities,
             premature tooth loss, abnormalities of eruption and position.

GOAL Dental Undifferentiated Signs and Symptoms. Evaluate and appropriately
treat or refer patients with commonly presenting dental signs and symptoms.

   A. Recognize, identify differential diagnosis, provide initial treatment as indicated
      and manage or refer patients with the following conditions:

          1. Dental pain or swelling
          2. Soft tissue pain of teeth, face, jaw or ear
          3. Infections of dental structures
          4. Dental trauma (loosening, displacement, avulsion, fracture)
          5. Dental staining (environmental, fluorosis, lead exposure, hereditary or
             genetic/syndromic, caries, white spots)
          6. Gingival swelling (medication-associated, chronic disease
             conditions)

GOAL Dental Common Conditions Not Referred. Diagnose and manage common
dental conditions that generally do not require referral.

   A. Diagnose and manage the following conditions:

          1.   Discomfort related to teething
          2.   Viral stomatitis (coxsackie, herpes virus)
          3.   Candidiasis
          4.   Minor injuries of the soft tissues of the mouth
          5.   Ulcers (traumatic, aphthous)
          6.   Cheilitis

   B. Diagnose developmental anomalies of the oral soft tissues that usually do not
      need referral.

          1. Lingular frenum (ankyloglossia) and maxillary frenum
          2. Geographic tongue
          3. Eruption cyst or hematoma

   C. Discuss with parents common oral habits and their effects on oral
      structures and assist in implementing a plan for behavior modification
      (e.g., bottle overuse/misuse, digit sucking, pacifier use, tongue thrust, lip
      sucking, bruxism)
   D. Discuss common oral and/or dental side effects of common pediatric
      medications (e.g., diphenylhydantoins, tetracyclines, immune
      suppressants) and their additives (e.g., sucrose).
GOAL Dental Conditions Generally Referred. Recognize, provide initial
management and refer appropriately patients with conditions that usually require
dental or oral surgery referral.

   A. Identify, provide initial management of pain and/or infection, and refer as needed
      children with the following conditions:

          1. Dental caries (including early childhood caries)
          2. Dental developmental anomalies (enamel, conical or misshapen teeth)
          3. Delayed eruption or eruption failure
          4. Premature exfoliation
          5. Missing teeth
          6. Staining of teeth
          7. Tooth injury secondary to trauma
          8. Cellulitis and dental abscess
          9. Gingivitis and periodontitis
          10. Gingival hyperplasia (hereditary or secondary to medications)
          11. Mucocele/ranula
          12. Parulis
          13. Premature tooth loss (traumatic)
          14. Maxillofacial trauma
          15. Malocclusion
          16. Craniofacial anomalies including cleft lip or palate
          17. Tobacco-induced mucosal changes
          18. Black hairy tongue
          19. Natal and neonatal teeth

   B. Anticipate dental care needs of patients with special medical conditions,
      including:

          1.   Mental retardation or cerebral palsy
          2.   Autism
          3.   Congenital heart disease
          4.   Immunosuppression
          5.   Cardiac conditions
          6.   Oncologic conditions
          7.   Spina bifida
          8.   Coagulopathies

   C. Recognize oral manifestations of the following systemic diseases and respond or
      refer appropriately:

          1. Acute lymphoblastic leukemia
          2.   Sickle cell anemia
          3.   Hemophilia
          4.   Diabetes mellitus
          5.   Immunocompromised patients (HIV)
          6.   Neutropenia
          7.   Langerhans cell histiocytosis
          8.   Metabolic diseases

   D. Identify the role and general scope of practice of a dentist, dental
      hygienist, and oral surgeon; recognize situations where children benefit
      from the skills of pediatric specialists vs. generalists; and work effectively
      with these professionals in the care of children.

GOAL Dental Dental Caries. Prevent, diagnose and manage with appropriate
referral all cases of dental caries.

   A. Encourage initiation of infant tooth care with first erupted tooth.
   B. Counsel initiation of soft toothbrush use at approximately 12 months.
   C. Recommend first visit to the dentist by age 12 months or at earliest
      possible time thereafter if there are obstacles to accessing pediatric dental
      care.
   D. Encourage families to develop good oral hygiene habits and maintain
      dental office visits.
   E. Discuss avoidance of cariogenic feeding practices (prolonged use of bottle
      or "sippy" cup, for pacification and not feeding).
   F. Educate families about cariogenicity of high-sucrose and other
      carbohydrate diets.
   G. Recommend initiation of fluoride-containing dentifrice at an age when
      swallowing can be minimized.
   H. Screen all children at every health maintenance visit for dental caries and
      recognize patients at risk for dental caries.
   I. Diagnose white spot caries and cavities and refer for treatment.
   J. Recognize and refer patients with signs and symptoms of dental abscess and
      anticipate the potential complications such as Ludwig angina, cavernous sinus
      thrombosis, orbital cellulitis, sinusitis and epidural abscess.

GOAL Dental Dental Trauma. Prevent, diagnose and manage with appropriate
referral cases of dental trauma.

   A. Counsel children and families regarding risk of dental trauma during childhood.
   B. Educate families regarding emergency procedures to follow in case of avulsed
      tooth, e.g., why re-implantation at the earliest possible time is important and how
      to store and transport an avulsed permanent tooth (using specialized transport
      media, milk).
   C. Advise children and families regarding use of protective gear during sports
      (helmet with face shield, mouthguard).
   D. Recognize and refer types of dental injury (both acute and late findings):

          1.   Concussion
          2.   Subluxation, lateral luxation
          3.   Intrusion, extrusion
          4.   Avulsion
          5.   Fracture, exposed pulp




GOAL: Demonstrate high standards of professional competence while working with
patients in the continuity and outpatient setting.
      A. Patient Care Provide family-centered patient care that is development
      and age-appropriate, compassionate, and effective for the treatment of
      health problems and the promotion of health
          Use a logical and appropriate clinical approach to the care of
             outpatients, applying principles of evidence-based decision-making
             and problem solving.
          Provide sensitive support to patients and their families in the outpatient
             setting.
          Provide effective preventive health care and anticipatory guidance to
             patients and families in continuity and outpatient clinics.
      B. Medical Knowledge. Understand the scope of established and evolving
      biomedical, clinical, epidemiological and social-behavioral knowledge
      needed by a pediatrician; demonstrate the ability to acquire, critically
      interpret and apply this knowledge in patient care.
          Demonstrate a commitment to acquiring the base of knowledge needed
            for care of children in the continuity and general ambulatory
            setting.
          Know and/or access medical information efficiently, evaluate it
             critically, and apply it to outpatient care appropriately.
      C. Interpersonal and Communication Skills. Demonstrate interpersonal
      and communications skills that result in information exchange and
      partnering with patients, their families and professional associates.
          Provide effective patient education, including reassurance, for
             conditions common to the outpatient setting.
   Communicate effectively with physicians, other health professionals,
     and health-related agencies to create and sustain information
     exchange and teamwork for patient care.
   Develop effective teaching strategies for teaching students, colleagues,
      other professionals and lay persons.
   Maintain accurate, legible, timely, and legally appropriate medical
      records in the Continuity Clinic and Pediatric Outpatient
      Department.
D. Practice-based Learning and Improvement. Demonstrate knowledge,
skills and attitudes needed for continuous self-assessment, using scientific
methods and evidence to investigate, evaluate and improve one’s patient
care practice.
   Identify standardized guidelines for diagnosis and treatment of
      conditions common to outpatient pediatrics, and adapt them to the
      individual needs of specific patients.
   Work with health care team members to assess, coordinate, and
     improve patient care in the outpatient setting.
   Establish an individual learning plan, systematically organize relevant
      information resources for future reference, and plan for continuing
      acquisition of knowledge and skills.
E. Professionalism. Demonstrate a commitment to carrying out
professional responsibilities, adhering to ethical and legal principles, and
sensitive to diversity.
   Demonstrate personal accountability to the well being of patients (e.g.,
     following-up lab results, writing comprehensive notes and seeking
     answers to patient care questions).
   Demonstrate a commitment to professional behavior in interactions
     with staff and professional colleagues.
   Adhere to ethical and legal principles and be sensitive to diversity.
F. Systems-Based Practice. Understand how to practice high quality
health care and advocate for patients within the context of the health care
system.
   1. Identify key aspects of outpatient health care systems (e.g., public
      and private insurance) as they apply to the primary care provider,
      such as the role of the PCP in decision-making, referral and
      coordination of care.
   2. Demonstrate sensitivity to the costs of clinical care in the
      outpatient setting and take steps to minimize costs without
      compromising quality.
   3. Recognize the limits of one’s knowledge and expertise and take
      steps to avoid medical errors.

				
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