What Problems Do I Need to Screen This New International Adoptee or Domestic Foster Care Child For?

Patient Presentation
A pediatrician noticed that a 5-year-old male was coming for an initial visit later in the week. The scheduling notes said that he was recently adopted from Africa. The pediatrician has no other information available but wanted to review what evaluation should be completed during the visit. A search of the American Academy of Pediatrics website for policies and guidelines revealed several regarding international adoption. The search also brought up several references for evaluation for children in foster care. The pediatrician planned to also review the Centers for Disease Control website for traveler’s health information once the country or area of Africa was known.

Discussion
There is much overlap between immigrant children and children in foster care – particularly around adoption. Immigrant children are defined as those who are legal and undocumented immigrants, refugees and international adoptees. Children in domestic foster care if not reunified with their parents may be adopted by relatives (kinship permanency) or with non-relatives (national adoptees). Additionally, international adoptees and children initially or recently placed into foster care need similar medical evaluations.

Children that are adopted, including those who had been in foster care, have higher rates of asthma, moderate or severe health problems, developmental delays, psychosocial problems (problems with emotion, concentration, behavior, getting along with others, etc. ), learning disabilities and school difficulties and are more likely to have special health care needs. Fifty percent or more of international immigrants have at least 1 health problem. Eighty percent of the health problems may not be evident by history or physical examination and 60% of the health problems are infectious disease related.

Learning Point
Health care evaluations for immigrant and foster care children are similar as both groups need good general care and screening for appropriate problems and treatment. International adoptees have a higher risk for tropical infectious diseases, while children in domestic foster care may have higher risks for physical and sexual abuse. Obviously a thorough review of all medical records available and a thorough history and physical examination should alert the health care provider to specific concerns for a child that need to be specifically addressed (e.g. immigration to South East Asia, exposure to substance abuse, etc.).

An evaluation for international adoptees and children in foster care could include:

  • General
    • Review of all medical records *^+
    • Complete history and physical examination *^
      • Growth parameters ^
      • Development *^+
      • Signs of trauma or abuse ^
      • Genital and anal examination ^
    • Dental examination *^
  • Screening
    • Vision and hearing *
    • Psychosocial evaluation *^+
      • Adaptation to new home +
      • Anxiety
      • Depression
      • Grief
      • Posttraumatic stress disorder
      • School problems and learning disabilities +
    • Laboratory
      • Infectious Disease
        • Hepatitis A
        • Hepatitis B *+
        • HIV as appropriate *^+
        • Sexually transmitted infections, as appropriate ^+
        • Syphilis, congenital
        • Tuberculosis *
      • Preventive Health
        • CBC *
        • Urinalysis *
        • Lead *
        • Neonatal screening
    • Treatment, as appropriate but usually treated presumptively
      • Malaria *
      • Intestinal parasites * including amebiasis, schistosomiasis
      • Immunizations *+

* Recommended by the Centers for Disease Control for new immigrants and refugees within 3 months of arrival into the United States.
^ Recommended for initial health screening for foster care placement.
+ Recommended for comprehensive health screening for foster care placement (within 1 month of placement)

Routine screening for Hepatitis A, B, D and E is not indicated. Many immigrant children are behind the normal growth parameters for US born children but have significant catch-up growth in 1 year. As many as 75% of immigrant children have dental disease upon entry to the US. Immunization records that are incomplete or suspicious should be considered underimmunized and catch-up vaccination begun.

Many adoptive families have concerns about communicating with their children and others about the adoption or foster care and its circumstances. The American Academy of Pediatrics has recommendations regarding the developmental understanding and communication about adoption. See the To Learn More section.

Questions for Further Discussion
1. What mental health services are offered in my community for international adoptees and children in foster care?
2. What school related services are offered in my community for international adoptees and children in foster care?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed for Adoption</a.
and
PubMed for Foster Care.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Adoption and Family Issues.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

American Academy of Pediatrics. Initial Medical Evaluation of an Adopted Child. Pediatrics. 1991:88.

American Academy of Pediatrics. Health Care for Children of Immigrant Families. Pediatrics. 1997:199;153-156.

American Academy of Pediatrics. Health Care of Young Children in Foster Care. Pediatrics. 2002:109: 536-541.

American Academy of Pediatrics Policy Statement. Familes and Adoption: The Pediatrician’s Role in Supporting Communication. Pediatrics. 2003:112;1437-1441.

Bramlett MD, Radell LF, Blumberg SJ. The Health and Well-being of Adopted Children. Pediatrics. 2007:119;s54-s60.

Walker PF, Stauffer WM, Barnett ED. Centers for Disease Control. Traveler’s Health Yellow Book. Chapter 9. Health Consideration for Newly Arrived Immigrants and Refugees. Available from the Internet at: http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-9/after-arrival-in-the-us.aspx (rev. 7/29/2009, cited 9/15/09)

ACGME Competencies Highlighted by Case

  • Patient Care
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are Those Blood Group Antigens and Isn't There Some Treatment I Can Give?

    Patient Presentation
    A 3-day-old female came to clinic because the parents felt she wasn’t feeding as well as she should. She had been feeding every 2-3 hours but her mother only began lactating a couple of hours previously. She was urinating and having bowel movements per her parents. They denied any temperature instability and felt she was alert. The past medical history showed she was a 36 0/7 week premature infant born by spontaneous vaginal delivery to a first time mother with a history of anti-C antibody. She had been discharged from an outside hospital 12 hours previously. Birthweight was 2550 g and bilirubin level was 5.2 at 14 hours of age. The family history was negative for premature births, spontaneous abortions, hematological, oncological, or gastrointestinal diseases. The review of systems was otherwise negative. The pertinent physical exam showed a tired appearing infant who was markedly jaundiced over her entire skin. Her weight was 2410 g. Other growth parameters were 50%. She had moist mucous membranes. Her head had a small bruise that crossed the midline of the distal occiput that was 2 cm in size and soft. Her abdomen was soft with no hepatosplenomegaly. The rest of her examination was normal.

    The diagnosis of hyperbilirubinemia in a premature infant with possible alloantibodies was made. The initial work-up of a bilirubin showed a bilirubin of 18.9 at 71 hours of life. She was begun on phototherapy and further evaluation and treatment started. However a repeat bilirubin level two hours later had increased to 19.2 which is just below the level for exchange transfusion, so she was transferred to the neonatal intensive care unit for probable hemolytic disease of the newborn. The patient’s clinical course showed that she was aggressively treated with phototherapy, hydration, and antibiotics for possible sepsis (cultures were eventually negative). She was also treated with intravenous immunoglobulin for possible alloimmunization, even though her Coombs test and blood smear were negative. There was no evidence of platelet or leukocyte problems. She was taken off phototherapy 2 days later and was able to be discharged home on day 3. She was to followup with her physician in 2-3 days.

    Discussion
    Hemolytic disease of the newborn is usually considered if there is a severe or rapidly developing hyperbilirubinemia, a maternal positive antenatal antibody screening or severely anemic or hydropic fetus, a positive direct Coombs test, hemolysis seen on blood smear, or prolonged hyperbilirubinemia. A differential diagnosis of the multiple causes of unconjungated hyperbilirubemia can be found in a previous case, and a review of the epidemiology of Rh negative HDN can also be found in another previous case.

    Learning Point
    Causes of severe unconjungated hyperbilirubinemia due to red blood cells causes includes:

    • Major Blood Group Antigen
      • ABO incompatibility
      • Rhesus group incompatibility (Anti-D, Anti-C and Anti-E)
    • Minor Red Blood Cell Antigens
      • Anti-Duffy
      • Anti-Kell
      • Anti-Kidd
      • Anti-MNS system (Anti-U)
    • Enzyme Disorders
      • Glucose-6-phosphate dehydrogenase deficiency
      • Pyruvate kinase deficiency
      • Trisephophate isomerase deficiency
      • Disorders of glycolysis pathway
    • Hemoglobinopathies
      • Alpha Thalassemia
      • Globin chain variants, especially alpha and gamma
    • Membrane Disorders
      • Hereditary elliptocytosis
      • Hereditary spherocytosis
      • Hereditary pyropoikilocytosis
      • Hereditary stomatocytosis

    The Rhesus antigen D (RhD) is the most important clinically because it is developed early in gestation, it is immunogenic, a significant percentage of the Caucasian population is RhD negative and the RhD antibody can cause fetal hemolysis.

    Data for use of intravenous immunoglobulin (IVIG) began to be published approximately 20 years ago. Two recent systematic reviews have advocated for the judicious use of IVIG as an effective and safe treatment for reducing the need for exchange transfusion in HDN. The American Academy of Pediatrics guidelines for treatment of jaundice also recommends use of IVIG if the bilirubin continues to increase despite intensive phototherapy or if the level is within 2-3 mg/dl of exchange transfusion levels.

    Questions for Further Discussion
    1. How would you treat isoimmune thrombocytopenia?
    2. What is the differential diagnosis of conjugated hyperbilirubinemia?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Jaundice and at Pediatric Common Questions, Quick Answers for this topic: Jaundice.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hadley AG. Laboratory assays for predicting the severity of haemolytic disease of the fetus and newborn.
    Transpl Immunol. 2002 Aug;10(2-3):191-8.

    American Academy of Pediatrics Clinical Practice Guideline Statement. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics. 2004;114:297-316. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/1/297 (cited 9/11/09).

    Murray NA, Roberts IA. Haemolytic disease of the newborn.
    Arch Dis Child Fetal Neonatal Ed. 2007 Mar;92(2):F83-8.

    Alcock GS, Liley H. Immunoglobulin infusion for isoimmune haemolytic jaundice in neonates. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.: CD003313. DOI: 10.1002/14651858.CD003313.

    Walsh S, Molloy EJ. Towards evidence based medicine for paediatricians. Is intravenous immunoglobulin superior to exchange transfusion in the management of hyperbilirubinaemia in term neonates? Arch Dis Child. 2009 Sep;94(9):739-41.

    ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Is There Arsenic in My Environment?

    Patient Presentation
    A pediatrician was at a professional conference and was discussing lead toxicity with some colleagues. One person made the comment that lead was a huge problem but he also had to deal with arsenic in his area. The pediatrician registered surprise and inquired why. The other pediatrician noted that in his area there were many military installations and therefore there was contaminated soil. He said that building ordinances only allowed building down to a certain depth to minimize potential exposure and ground water was monitored closely. The pediatrician was interested in finding out if there was arsenic in her local environment and found a map of arsenic in ground water for the United States from the National Geological Survey. Unfortunately there was no data for her area.

    Discussion
    Arsenic (As) is a semimetal found in Group 15 of the Periodic Table of Elements which is shared by Nitrogen, Phosphorus, Antimony and Bismuth. It is not considered by chemists as a heavy metal, but is often lumped in with Mercury and Lead because all have similar toxic affects. Elemental arsenic is not toxic itself, but inorganic and organic compounds are toxic. Trivalent inorganic compounds are particularly toxic because they are highly lipid soluble. Arsenic is bound by plasma proteins, hemoglobin and leukocytes and then is concentrated in the gastrointestinal tract, liver, kidneys, spleen, and lungs. Acute toxicity can cause an acute paralytic syndrome with cardiovascular collapse, central nervous depression and death within hours. It can also cause an acute gastrointestinal syndrome including acute vomiting and hematemesis, profuse diarrhea and hematochezia. Acute multiorgan system failure can then occur. Chronic toxicity usually has skin changes (i.e. melanosis, keratosis) and peripheral neuropathy as common presentations. Arsenic is also a carcinogen.

    Exposures to arsenic include:

    • Environment – water, air, marine animals, and fossil fuels. Fruits, vegetables, milk and rice can also be contaminated, as can glues and pigments.
    • Industrial exposures through manufacturing glass and electronics, wood preservatives, metal alloy hardening, and pesticides and herbicides.
    • Arsenic is also used as a poison for suicide or homicide. Arsenic can be used as a vesicant or inhalation chemical warfare agent.

    Children are most likely to encounter arsenic through contaminated food and water and through pesticides and herbicides. Adults are most likely to encounter arsenic through occupational exposure.

    Arsenic levels are best determined from a 24 hour urine sample, as blood is unreliable. Treatment includes decontamination and chelation therapy using 2,3-dimercaptopropanol (aka BAL) and Dimercaptosuccinic Acid (DMSA).

    Learning Point
    The United States National Geological Survey made several maps of arsenic in ground water in 2001, with data collected from public and private water supplies. In many areas of the country no data is available. This is particularly true in rural areas where many people rely on ground wells which are generally unregulated.

    Like any scientific data, the maps can be interpreted in many different ways and the American Geological Institute published an article describing some of these nuances:

    “If the question is, “Where are the most people exposed to arsenic?” the resulting map might point to areas of dense population relying on large public water supply systems. To answer, “Where are people exposed to the highest levels of arsenic?” a map might finger rural areas where private wells containing high arsenic concentrations commonly go untreated. A map answering, “Where will reducing arsenic be most costly?” could identify areas with the greatest number of wells high in arsenic; or where high arsenic occurs with high sulfate; or where drilling new wells may be required. These different “treatment cost” maps may not point to the same areas that other maps highlight to show the “most population” and “highest arsenic.””

    For much of the country there is no available data. However, the maps can give health care providers some idea if their patients and themselves are potentially living in an environment where arsenic is a problem.

    One paper using a statistical model estimated that 8.2% of the area of the United States is potentially contaminated. This is contrasted with other global areas particularly South East Asia in Bangladesh (35.4%) and Cambodia (45.8%) and Vietnam (15.8%). If the arsenic problem is measured in other terms (such as the number of people estimated to be drinking contaminated water) Bangladesh is by far the country with the worst arsenic problem.

    Questions for Further Discussion
    1. Is your local environment contaminated with arsenic?
    2. What are the clinical signs of mercury toxicity?
    3. What are the clinical signs of lead toxicity?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Arsenic

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Cullen NM, Wolf LR, St Clair D. Pediatric arsenic ingestion. Am J Emerg Med. 1995 Jul;13(4):432-5.

    U.S. Geological Survey, 200212, Arsenic in Ground Water of the United States: National Atlas of the United States, Reston, VA.
    Available from the Internet at http://water.usgs.gov/nawqa/trace/arsenic/ (cited 9/10/09).

    Ryker S. Mapping arsenic in groundwater. Geotimes. Available from the Internet at http://www.agiweb.org/geotimes/nov01/feature_Asmap.html (rev. 11/2001, cited 9/10/09).

    Amini M, Abbaspour KC, Berg M, Winkel L, Hug SJ, Hoehn E, Yang H, Johnson CA. Statistical modeling of global geogenic arsenic contamination in groundwater. Environ Sci Technol. 2008 May 15;42(10):3669-75.

    Rahman MM, Ng JC, Naidu R. Chronic exposure of arsenic via drinking water and its adverse health impacts on humans. Environ Geochem Health. 2009 Apr;31 Suppl 1:189-200.

    ACGME Competencies Highlighted by Case

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What is the Appropriate Treatment for a Pedal Puncture Wound?

    Patient Presentation
    A pediatrician received a telephone call from a local physician regarding a 10-year-old male who came to his office with a puncture wound to his bare foot that occurred a couple hours ago. The child had been wading in a river and did not know what had been stepped on. The child was previously healthy. No other history was available as the physician was hurried and wanted to know if Ciprofloxacin could be given to a 10 year old. The pediatrician answered yes that it could be given but that other antibiotics were probably more appropriate. The physician stated that he was very concerned about possible Pseudomonas, even when the pediatrician pointed out that the child had been barefoot and that the injury had just occurred. She noted that Staphylococcus and Streptococcus were the more likely organisms. He insisted that he was going to give Ciprofloxacin as the pediatrician had said that it could be used in children. The pediatrician helped the physician choose an appropriate dosing regimen for the Ciprofloxacin and also reminded the physician that the child should receive a tetanus shot as the child was 10 years old and most likely 5 years or more probably had elapsed since his last tetanus vaccination.

    Discussion
    Ciprofloxacin and other fluoroquinolones have demonstrated cartilage and joint toxicity when administered to immature laboratory animals. Therefore health care providers have been reluctant to use fluoroquinolones in young children and voluntarily have avoided them. However in 2002, more than 182,000 courses of fluoroquinolones were administered to children. Research data is limited but the pediatric safety profile appears to be similar to the adult safety profile. Current indications for fluoroquinolones include complicated urinary tract infections, treatment of opportunistic infections in immunocompromised patients such as patients with cancer, patients with cystic fibrosis and certain Shigella and Salmonella infections, and for inhalational anthrax. Fluoroquinolones are often considered second line antibiotics for specific indications and should be used only when indicated.

    Learning Point
    Puncture wounds of the foot are common presentations to the office or emergency room. Punctures are caused by a variety of objects including nails, needles, plastic, metal, organic materials and glass. The foot has an increased risk of secondary infection owning to the structure of the foot and its increased cartilage. There is a higher risk of infection the deeper the puncture is and the more distal on the foot (i.e. a deep puncture around the metatarsalphalayngeal joint). Most infections actually are relatively superficial with Staphylococcus and Streptococcus predominating, particularly in the first 24 hours after injury. Pseudomonas aeruginosa is a frequent cause of deep seated infections such as osteochondritis or osteomyelitis. Pseudomonas is a known contaminate of the soft inner foam lining of tennis shoes. One study found Pseudomonas only occurred in patients wearing foot gear when the trauma occurred. Other organisms include Bacteroids, E. coli, Klebsiella and Serratia.

    Patients who present with a puncture wound should have the wound thoroughly examined, possibly explored, and debrided. A retained foreign body is a possibility even with thorough examination. Standard radiographs and possibly ultrasound or magnetic resonance imaging may be indicated if a retained foreign body is suspected. Some physicians use providine-iodine solutions as part of the thorough cleaning of the wound. Hexachlorophene should not be used as open bottles may become colonized with Pseudomonas. Tetanus prophylaxis should also be assessed for any patient and given if appropriate.

    Children who present within 24 hours with a clean wound, and with low suspicion for a retained foreign body often can be treated conservatively. These children usually do well with few complications. Prophylactic oral antibiotics against Streptococcus and Staphylococcus are usually given to patients who are high risk (such as diabetics), or with wounds at the metatarsalphalangeal joint to distal to it. Patients should be re-examined in 1-2 days. For patients not improving, a retained foreign body must be considered and the patient usually needs parental antibiotics. Again the antibiotic choice usually is against Streptococcus and Staphylococcus, but Pseudomonas should be considered if foot gear was worn during the trauma.

    For patients presenting 24-72 hours after injury, prophylactic oral antibiotics against Streptococcus and Staphylococcus is usually begun empirically, with appropriate initial management and followup. Patients presenting > 72 hours after injury with pain, erythema, swelling etc, should be started on parental antibiotics against Streptococcus and Staphylococcus, and also against Pseudomonas if foot gear had been worn. Patients presenting after 72 hours usually have a high rate of complications.

    Questions for Further Discussion
    1. As the treating physician, how would you have treated the patient presented above?
    2. As the consulting physician, how would you have handled this telephone call?
    3. What is a common organism found in animal puncture bites?
    4. How would you treat a puncture wound to another body site?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Foot Injuries and Disorders and Wounds.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Laughlin TJ, Armstrong DG, Caporusso J, Lavery LA. Soft tissue and bone infections from puncture wounds in children.
    West J Med. 1997 Feb;166(2):126-8.

    Eidelman M, Bialik V, Miller Y, Kassis I. Plantar puncture wounds in children: analysis of 80 hospitalized patients and late sequelae.
    Isr Med Assoc J. 2003 Apr;5(4):268-71.

    Chachad S, Kamat D. Management of plantar puncture wounds in children.
    Clin Pediatr (Phila). 2004 Apr;43(3):213-6.

    Grady RW. Systemic quinolone antibiotics in children: a review of the use and safety.
    Expert Opin Drug Saf. 2005 Jul;4(4):623-30.

    ACGME Competencies Highlighted by Case

  • Patient Care

    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital