How Common is Tetanus?

Patient Presentation
An 11-year-old female came to the emergency room with increasing muscle spasms over the past 3 days. She initially complained of neck soreness which progressed to her back. Drinking and swallowing became more difficult. These episodes increased to spasms with relaxation of the muscles in between. The spasms became worse in the morning involving her arms and legs and became more frequent. She lived on a farm and was well-known not to wear shoes often. The past medical history revealed that she was unimmunized.

The pertinent physical exam upon arrival in the emergency room showed her to have an episode where her entire body went rigid with severe back arching and a scared expression on her face. This occurred for about 10 seconds and then she became relaxed, still appeared scared and indicated general pain. A puncture wound on her left heel showed mild induration. She had several more opisthotonic episodes while in the emergency room. The pertinent laboratory evaluation included negative drug testing, and an electroencephalogram showed no seizure activity. The diagnosis of tetanus was made. The patient’s clinical course at 24 hours showed that she had been given tetanus immune globulin and was mechanically ventilated. Her puncture wound had been surgically debrided and she was receiving antibiotics. At one week she was slowly improving.

Case Image
Figure 90 – Painting by Sir Charles Bell in 1809 showing opisthotonus. Dr. Bell was a surgeon and anatomist most well known for Bell’s palsy.

Discussion
Clostridium tetani is a gram-positive bacillus that is anaerobic and spore forming. Tetanus spores are found universally worldwide in the soil and the stool of animals and people. Contamination through the skin in wounds (especially deep puncture wounds) and the umbilicus are the primary entry points. It is not unusual for the organism not to grow in cultures. The bacteria grows in dead tissues and produces a potential neurotoxin which blocks the myoneural junction. Symptoms occur gradually over 1-7 days and progress to opisthotonus. These spasms are often provoked by external stimuli. The spasms persist for about 1 week and then subside over a period of weeks in those who recover.

Opisthotonus can also be caused by other diseases such as Sandifer syndrome, and phenothiazines and strychnine.

Tetanus is not transmitted person to person and herd immunity cannot help prevent the disease. Primary immunization series for tetanus in the U.S. is at 2, 4,and 6 months of age, with the 4th dose 6-12 months after the 3rd dose, and the 5th dose at ages 4-6 years with DTaP. Pre-teens and teenagers with no history of tetanus vaccination are recommended to receive 3 vaccinations, preferably with Tdap, followed by Td after 4 weeks, and then third dose 6-2 months after the earlier Td dose. Tdap can be substituted for another dose in the series though.

Treatment for tetanus includes:

  • Tetanus immune globulin given IM in one injection
  • Metronidazole for 10-14 days to decease the number of vegetative forms
  • Debridement of the wound
  • Supportive treatment for tetanic spasms and respiratory failure

Learning Point
Primary immunization and improved obstetrical/neonatal care has significantly decreased the cases and deaths worldwide caused by tetanus. However, in 2008, ~61,000 children (about 1% of children) still died from tetanus. Most of these were neonates. A trend graph shows the number of tetanus cases/year markedly decreasing as the immunization rate also increases. Low immunization rates (under 50%) are seen most often in India and Africa

In the United States in 2008, 18 cases of tetanus were reported with no deaths. From 2005-2009, 133 cases of tetanus were reported in the U.S. There is clear evidence that tetanus disease occurs because of parental objection to vaccination. As there is no method for prevention of tetanus other than immunization, parents must be educated and advised of the seriousness of the disease. Herd immunity which some parents wish to rely on for other diseases (such as pertussis) does not apply for tetanus.

Questions for Further Discussion
1. How do you educate parents about the risks of vaccine preventable diseases?
2. What are medical contraindications to tetanus vaccine?
3. What are the barriers to vaccination in your local community?
4. In what circumstances would no vaccination or undervaccination be considered child neglect?

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: Tetanus

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

To view images related to this topic check Google Images.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1006-07.

American Academy of Pediatrics. Tetanus, In Pickering LD, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th edit. Elk Grove Village, IL: American Academy of Pediatrics; 2009;665-660.

Summary of recommendations for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) and tetanus and diphtheria toxoids (Td) use among adolescents aged 11–18 years. MMWR. March 24, 2006 / 55(RR03);37-38. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5503a4.htm (cited 9/20/10).

World Health Organization. Tetanus. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/tetanus/en/index.html (rev. 3/26/2010, cited 9/20/10).

World Health Organization. Maternal and Neonatal Tetanus (MNT) elimination. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/MNTE_initiative/en/index2.html (rev. 7/5/10, cited 9/20/10).

Notifiable Diseases and Mortality Tables. MMWR. June 4, 2010 / 59(21);662-675. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5921md.htm#tab3 (cited 9/20/10).

Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L, Mathers C; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: a systematic analysis. World Health Organization and UNICEF. Lancet. 2010 Jun 5;375(9730):1969-87. Available from the Internet at http://www.who.int/immunization_monitoring/diseases/Lancet_2010_withAppendix.pdf (cited 9/20/10).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    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
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • 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

  • How Common is Lower Gastrointestinal Bleeding in Athletes?

    Patient Presentation
    A 17-year-old female came to clinic for her health supervision visit. She was a cross-country runner and denied any injuries since her last visit. She did complain of increased stooling that was more liquid in consistency. Occasionally she noticed a small amount of blood after long runs or increases in mileage, but never any clots or frank hematochezia. She did complain of some bloating and gas during training and races, but denied gastroesophageal reflux. She ate a varied diet and took a multivitamin with iron. She denied changes in menstruation or more than 2-3 pounds weight change. The past medical history was non-contributory. The family history showed a paternal great uncle with colon cancer in his 80s. The review of systems was negative.

    The pertinent physical exam showed a well developed female with her weight at the 10%, and height at the 75%. Abdominal examination was negative including a rectal examination. Stool hemoccult was negative. The laboratory evaluation showed a hemoglobin of 12.8 gm/dl, platelets of 240 x 1000/mm2 and a smear that was normal. Iron studies were also normal. The diagnosis of intermittent gastrointestinal bleeding due to exercise was made. She was instructed to increase the time between eating and training, limit gas-forming foods and fiber-rich foods in addition to keeping well hydrated. She was also told to increase her training more steadily. She said that she could do the first parts, but that the training schedule during the season was up to her coach. The patient’s clinical course showed stool hemoccults to be positive after her long runs, but were negative during less intensive training. During the off-season when she reduced her mileage she had no positive hemoccults.

    Discussion
    Sports are a healthy recreational and social activity. However, various changes to the body inherent with the activity or because of increased intensity or volume of training and/or competition may cause problems for recreational and competitive athletes.

    Gastrointestinal (GI) symptoms occur in 30-65% of long distance runners. Upper gastrointestinal problems include nausea, emesis, gastroesohpageal reflux, and ulcers. Upper GI problems are more common in cyclists than runners though. Treatment includes avoiding eating within 3 hours of running, antacids and H2-blockers.

    Lower GI tract problems include cramping, increased defecation urge, increased bowel frequency and diarrhea. One well-documented serious problem is ischemic colitis. Potential causes include dehydration, decreased splanchnic blood flow, changes in sympathetic/parasympathetic tone, hormonal changes and mechanical effects. Treatment includes decreasing gas-forming foods, caffeine, and fiber-rich foods, maintaining hydration, and changing training and competition volume and intensity (i.e. working up to a higher level slowly). Oral contraceptives and non-steroidal anti-inflammatory medications may also contribute to gastrointestinal bleeding and therefore modification in their use may also help.

    A differential diagnosis of GI bleeding can be found here.

    Learning Point

    Most studies of GI bleeding are in highly competitive athletes such as marathon runners and therefore there is less information about recreational runners. Studies of marathoners and ultramarathoners found occult blood in the stool after a race occurs in 8-85% of athletes. One study of adult recreational triathletes (averaging 11 hours training/week of 2 miles of swimming, 16 miles of running and 46 miles of biking) found that 50% reported bloating and abdominal gas and 27% had positive hemoccult stools.

    GI bleeding occur in others sports also but again is less well documented. A case study of a rugby player had exercise-induced occult bleeding after 20 minutes of playing time in an international qualifying match.

    Questions for Further Discussion
    1. What evaluation should be considered for lower gastrointestinal bleeding?
    2. What are the indications for endoscopy?
    3. What is the differential diagnosis for anemia in an athlete?

    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: Gastrointestinal Bleeding

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

    To view images related to this topic check Google Images.

    Worme JD, Doubt TJ, Singh A, et.al. Dietary patterns, gastrointestinal complaints, and nutrition knowledge of recreational triathletes. Am J Clin Nutr. 1990:51;690-7.

    Babic Z, Papa B, Sikirika-Boxnjakovic M, et.al. Occult gastrointestinal bleeding in rugby player. J Sports Med Phys Fitness. 2001;41;399-402.

    Simons SM, Kennedy RG. Gastrointestinal problems in runners. Curr Sports Med Reports. 2004:3;112-116.

    Sanchez LD, Tracy JA, Berkoff D, Pedrosa I. Ishcemic colitis in marathon runners: A case-based review. J. Emer Med. 2006:30;321-326.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    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.
    5. Patients and their families are counseled and educated.
    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.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

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

  • When Can A Child Stay Home Alone?

    Patient Presentation

    An 11-year-old male came to clinic for a health supervision visit. He had no health, developmental, behavioral or social concerns. The diagnosis of a healthy pre-teen was made. When the resident was staffing the patient, he noted that the patient was being left alone for short periods of time after being dropped off from sports practice until the parents came home from work. This occurred twice per week for about 20 minutes. The resident felt the child was mature enough to be left alone but asked what the laws were in the state regarding the issue. He and the staff did a brief Internet search and found the state’s Department of Human Services website which stated that the state did not have an absolute age, but did have guidelines regarding issues to consider to help determine if a child was being neglected.

    Discussion
    There is no one right answer to the difficult decision of when can a child be left home alone safely. Parents need to consider the individual child and circumstances. The majority of states also do not have legal definitions of when a child can stay home alone and it not be considered neglectful, but may have guidelines. The Child Welfare Clearinghouse from U.S. Government has a list of state agencies that can be contacted by Internet or phone for more information (see To Learn More below). Generally children around 11-13 years can be ready to stay home alone. However, children even older may not be ready if they cannot show the maturity to handle the responsibility.

    Learning Point

    • Child’s General Readiness
      • Is the child physically and mentally able to care for himself?
      • Does the child obey rules and make good decisions?
      • Does the child feel comfortable or is fearful about being home alone?
      • Does the child have a sense of security and confidence in himself?
      • Does the child have the skills to handle boredom and fear?
      • How does the child handle unexpected situations? Can the child recognize danger or a dangerous situation?
      • Does the child handle personal responsibility such as homework, household chores? Does the child understand and follow rules? Does the child make good judgments or is he prone to taking risks?
      • Does the child understand expectations?
      • Will the child seek help from an adult if needed?
      • Does the child know and physically can perform safety measures?
    • Safety
      • Not only is it important to ask the child about these situations, it is important to have the child physically show that he can do what would be expected. For example, a child might know to go to the door and go outside if there is a fire, but may not be able to actually unlock the deadbolt lock. What would the child do then?
      • Does the child know what to do if:
        • They or someone gets cut or hurt
        • A stranger comes to the door
        • The telephone rings or someone calls for a parent who isn’t home
        • There is a severe weather alarm such as tornado
        • There is a power outage
        • A smoke alarm goes off
        • There is a small fire
        • Home alarm system goes off accidentally
        • What will the child do, when he doesn’t know what to do
      • Is the child physically able to demonstrate:
        • Opening doors, windows and locks
        • Operate the telephone or cellular telephone
        • Turn lights on and off
        • Operate food preparation equipment such as knifes, refrigerators, microwave oven, stoves, oven
        • Operate a home alarm system and what to do
        • Know when and how to call 911
        • Knows name, address, phone number, parents names and where the parent contact information is
        • Find and use the home first aid kit
    • Home Situation
      • How long will the child be alone for?
      • How often will this occur?
      • What time of day and/or night?
      • Is the child expected to care for siblings or animals?
      • Is the child expected to prepare a snack or meal?
      • Is the home safe?
      • Is the neighborhood safe?
      • Who or what would be the child’s resources to help solve a problem if they can’t contact the parent or until the parent could return to help?
    • Before the Child Stays Home Alone
      • Role play different scenarios and problems with the child
      • Establish rules including if and where the child may leave, TV/Computer/Internet use, doing homework and other household chores, when the child should call the parent.
      • Have a regular plan to check in with the child.
      • Review and talk about how the child is feeling and physically coping with staying home.
      • Have an emergency contact sheet readily available for the child.
      • Practice staying home for shorter time periods.
      • Review and talk about how the child is feeling and physically coping with staying home.
      • Reconsider if the child is still ready to stay home alone

    Questions for Further Discussion
    1. When is a child able to babysit/supervise other children?
    2. What is the definition of child neglect in your state?

    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: Child Safety

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

    To view images related to this topic check Google Images.

    Child Welfare Information Gateway. Leaving Your Child Home Alone. Available from the Internet at http://www.childwelfare.gov/pubs/factsheets/homealone.pdf (rev. 7/2007, cited 9/8/10).

    Child Welfare Information Gateway. Child Abuse Reporting Numbers. Available from the Internet at http://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=11-11172 (rev. 9/8/10, cited 9/8/10).

    Green N. Leaving Your Child Home Alone.KidsHealth.Available from the Internet at http://kidshealth.org/parent/firstaid_safe/home/home_alone.html# (rev. October 2010, cited 9/8/10).

    4C for Children. blogParents. Is My Child Ready? Available from the Internet at: http://blogparents.4cforchildren.org/ (rev. 07/21/2010, cited 9/8/10).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • 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.
    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.

    Author

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

  • What Kind of Stretching Exercises are Recommended for Positional Plagiocephaly?

    Patient Presentation
    A 4-month-old female came to clinic for her health supervision visit. Her mother was concerned about a flat spot on the back of her head. Her mother said that the infant was always placed on her back to sleep, at the same end of the crib and that over time “she always seems to want to put her head in the same direction.” Her mother stated that she did not spend much time on her stomach and spent a fair amount of time in a car seat sleeping. She did not roll over yet. The past medical history showed a normal head shape at 2 weeks of age. She was full term without problems. The family history was negative for neurological problems or early deaths.

    The pertinent physical exam showed a smiley female who would make spontaneous vowel sounds and transfer objects with her hands. Her head circumference was 25% and her length and weight were 75-90%. All were tracking appropriately. She had a right occipital flatness with her right ear slightly anteriorly displaced with no facial asymetry. Her anterior fontanelle was open. No obvious torticollis was observed. The rest of her examination including a neurological examination were normal. The diagnosis of positional plagiocephaly was made. The mother was instructed to decrease the amount of time in the car seat, increase the amount of time on her abdomen, and place her on her back but with her head on the opposite side of the crib. The mother wanted to see a “specialist” and a consultation with a pediatric neurosurgeon was made. The mother noted some improvement at the neurosurgeon’s visit and was reassured by normal skull radiographs. At followup by neurosurgery and her 6 month health supervision visit, the positional plagiocephaly had resolved.

    Case Image

    Figure 89 – 10-04-10 – AP and lateral radiographs of the skull demonstrates flattening and indentation of the occipital portion of the skull. The cranial sutures are all patent.

    Discussion
    Positional plagiocephaly (PP) is an asymmetric head shape caused by external pressure on the occiput or other area of the head. The prevalence has increased since the 1992 recommendations began in 1992 for placing infants on their back for sleeping to decrease the risk of sudden infant death syndrome. Overall the rates vary from 0.3%-48% for infants < 1 year old.

    Children are at higher risk for PP at 7 weeks if they are:

    • Male
    • First-born birth order
    • Having a preference for sleeping position
    • Head placed in same end of crib
    • Bottle feeding only
    • Same side feeding position
    • Low amount of time placed on abdomen (a.k.a. “tummy time”)
    • Slow motor milestone achievement

    In another study, mothers of infants with positional plagiocephaly at 6 weeks thought the infants were less active, and they themselves had lower educational attainment and were less likely to have attended pre- or ante-natal parenting classes.

    Craniosynostosis is caused by the premature fusion of 1 or more cranial sutures with abnormal head shape occurring. It usually occurs because of abnormal ossification called primary craniosynostosis. It can also occur because of abnormal brain growth called secondary craniosynostosis. Overall the incidence of craniosynostosis is 0.04-0.1%. with sagittal (50-58%) and coronal (20-29%) sutures being the most commonly affected.

    Learning Point
    The skull is maximally deformable around 2-4 weeks so parents should be educated to place the child on their back for sleeping but to alternate positions of the occiput. Parents should also be instructed to do tummy time with their infant when awake and when they are observing the infant. The child should not be left unattended on their abdomen. Decreasing the amount of time in car seats or other similar seating also helps to prevent PP (e.g. “if the child is not riding in the car, then they should not be in the seat.”). These same maneuvers also helps treat PP, along with placing the rounded side of the head down on the mattress when sleeping, and changing the position of the crib so the child looks out while lying on the rounded head side. Neck stretching with each diaper change (about 2 minutes) should be recommended. These exercises can be done as follows:

    “One hand is placed on the child’s upper chest, and the other hand rotates the child’s head gently so that the chin touches the shoulder. This is held for approximately 10 seconds. The head is then rotated toward the opposite side and held for the same count. This will stretch out the sternocleidomastoid. Next, the head is tilted so that the infant’s ear touches his or her shoulder. Again, the position is held for a count of 10 and repeated for the opposite side. This second exercise stretches the trapezius muscle.” Three repetitions per diaper change are recommended.

    If there is no improvement, referral to a pediatric neurosurgeon or other specialist trained to treat such conditions is recommended to determine if the correct diagnosis is made (or this is craniosynostosis instead) and if other treatment such as cranial molding or surgery is necessary. A physical therapist may also assist in managing torticollis if still present after initial treatment.

    Children aged 4-12 months responds best to cranial molding if necessary because of the great malleability of the infant skull. Treatment is usually for 2-3 months for best results. Treatment for craniosynosis is almost always surgery but PP may also require surgery if it is severe and resistant to more conservative treatment.

    Questions for Further Discussion
    1. Describe the physical examination for determining possible positional plagiocephaly or craniosynostosis.
    2. What are the risks for craniosynostosis?

    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: Uncommon Infant and Newborn Problems and Head and Brain Malformations.

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

    To view images related to this topic check Google Images.

    Persing J, James H, Swanson J, Kattwinkel J; American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery.
    Prevention and management of positional skull deformities in infants. Pediatrics. 2003 Jul;112(1 Pt 1):199-202.

    Hutchison BL, Thompson JM, Mitchell EA. Determinants of nonsynostotic plagiocephaly: a case-control study. Pediatrics. 2003 Oct;112(4):e316.

    van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, L’Hoir MP, Helders PJ, Engelbert RH. Risk factors for deformational plagiocephaly at birth and at 7 weeks of age: a prospective cohort study. Pediatrics. 2007 Feb;119(2):e408-18.

    Sheth RD, Iskandar BJ, Heger IM, Roy S. Craniosynostosis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/1175957-overview (rev. 7/23/2010, cited 9/7/10).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    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.
    5. Patients and their families are counseled and educated.
    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.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

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