What Are the Potential Complications of a Retropharyngeal Abscess?

Patient Presentation
A 21-month-old male came to an outside emergency department with fever, difficulty swallowing, and neck stiffness. The plain radiograph of the neck showed concern for a retropharyngeal abscess and the patient was transferred by helicopter for surgical evaluation and treatment. The radiologic evaluation at the referral hospital of a neck computed tomographic examination revealed an enlarged hypodense area anterior to the cervical vertebra with ring enhancement consistent with the diagnosis of signficant retropharyngeal abscess. He was taken to the operating room where a combined team of pediatric otolaryngologists and pediatric surgeons performed a transoral and lateral neck drainage of a significant retropharyngeal abscess. The patient was intubated for airway control because of the extent of the abscess but was extubated on post-operative day 2. The cultures grew methicillin-sensitive Staphylococcal aureus and the patient received a total of 10 days IV antibiotics and an additional 1 week of oral antibiotics. He was sent home with an additional 1 week of oral antibiotics and the patient’s clinical course at 1 week after discharge found him doing well.

Case Image
Figure 107 – CT examination of the neck performed with intravenous contrast shows a large retropharyngeal abscess that extends from the skull base to the mediastinum that displaces and compresses the airway and esophagus (top), which involves the carotid spaces bilaterally as well as the retropharyngeal space (middle), and encases the trachea and mediastinal vessels (bottom).

Discussion
Retropharyngeal abscesses (RPA) occur in the potential space bound anterior to the prevertebral fascia, posterior to the pharyngeal constrictor muscles and their fascia and laterally by the carotid sheaths and parapharyngeal space (another potential space lying laterally to the pharynx). The retropharyngeal potential space runs superiorally from the base of the skull to the mediastinum distally. It is the most common deep neck infection. In children under 4 years of age, retropharyngeal lymph nodes are present which regress after this age. RPA is most common in young children when these lymph nodes are present, with probable suppuration of these lymph nodes and extension of the infection. RPAs in children are most commonly preceded by an upper respiratory tract infection (45%) such as tonsillitis, pharyngitis, sinusitis or cervical lymphadenitis, a foreign body ingestion (27%) or idiopathic (28%) in one study. Adults have more history of trauma or instrumentation preceding RPA. The organisms most commonly associated with RPA are mixed oral flora with gram-positive organisms such as Streptococcus viridians, Staphylococcus aureus, and Staphylococcus epidermidis being common. Gram-negative organisms include Haemophilus influenza, Bacteroides species and Fusobacterium species. Similar organisms are seen in peritonsilar abscess also.

It can be difficult to discern other common infections from RPA as many patients will show fever, decreased oral intake, neck lymphadenopathy, neck swelling and sore throat. Patients who also show neck pain with movement, torticollis, trismis, drooling, dysphonia or stridor may be easier to recognize, but other severe infections such as laryngotracheobronitis, epigottitis and meningitis may also show these symptoms.

Evaluation includes many indications of infection and inflammation such as complete blood count, erythrocyte sedimentation rate and C-reactive protein but are not specific. Radiological methods are most helpful. Plain lateral soft tissues radiographs can show anterior widening of the soft tissue space and narrowing of the airway. Plain radiographs are 80-88% sensitive and 100% specific. Ultrasound can be used but can be difficult to obtain and a negative examination does not rule out RPA. Computed tomography is considered the gold standard for diagnosis with a homogenous hypodense mass with ring enhancement.

Treatment is with intranvenous antibiotics and most often surgical drainage via a transoral route but also lateral neck and/or extension into the chest cavity may be necessary. Supportive measures such as intubation or tracheostomy may also be necessary.

Learning Point
Complications of RPAs include upper airway obstruction, jugular vein thrombosis, vascular rupture and hemorrhage, bacteremia, septic shock, mediastinitis, pericarditis, pleural empyema, aspiration pneumonia (due to spontaneous rupture), meningitis, and epiglottitis. Recurrence occurs in 1-5% of patients. Death can occur in up to 40-50% of patients. Higher death rates are seen in adults than children.

Questions for Further Discussion
1. What antibiotics would be appropriate for empiric treatment of a retropharyngeal abscess?
2. Describe the common location of a peritonsilar abscess?

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: Abscess and Throat Disorders.

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

To view images related to this topic check Google Images.

Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. 2003 Mar-Apr;24(2):111-7.

Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004 Dec;118(12):919-26.

Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik TL. Retropharyngeal abscess in children: 10-year study. J Otolaryngol. 2004 Dec;33(6):352-5.

Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004 Dec;62(12):1545-50.

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.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    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

  • What Causes Spontaneous Pneumothorax?

    Patient Presentation
    A 4 month old male came to the emergency room with fever to 103° and cough for 48 hours. The coughing had been much worse over the past day but there was no apnea or cyanosis. The patient had not had anything to drink for the past 8 hours. The past medical history showed a full-term infant without neonatal problems. He was current on immunizations. The family history showed no pulmonary disease.

    The pertinent physical exam revealed a tired appearing male with a respiratory rate of 62, pulse of 114, with normal blood pressure and temperature. His pulse oximeter was 88% on room air. His capillary refill was 3 seconds. HEENT showed clear rhinitis. Lungs had some mild coarse breath sounds throughout the fields with decreased sounds on the right. The rest of his examination was normal. The work-up included a venous blood gas of pH= 7.34, CO2 = 38 and O2 of 56 with a base of -6. A respiratory viral panel was negative for influenza, respiratory syncytial virus and other viruses. A pertussis nasal swab was also negative. The radiologic evaluation of a chest radiograph showed a right upper lobe consolidation with a moderate apical/anterior pneumothorax and small pneumomediastinum. The diagnosis of bilateral lower lobe pneumonia and spontaneous pneumothorax and pneumomediastum was made. He was treated conservatively with oxygen at 100% by nasal canula, IV fluids and antibiotics for community-acquired pneumonia. He was slowly improving clinically after 5 days.

    Case Image
    Case Image

    Figure 105 – 06-20-13 – AP view of the chest demonstrates right upper lobe collapse, patchy bibasilar infiltrates felt to represent bacterial pneumonia, and pneumomediastium outlining the inferior border of the heart – a continuous diaphragm sign.
    Figure 106 – 06-20-13 – Left lateral decubitus view of the chest demonstrates a small right pneumothorax.

    Discussion
    “A pneumothorax is a collection of air in the pleural space, and it can be categorized into spontaneous, traumatic or iatrogenic. Spontaneous pneumothorax can be further classified into primary with no clinical evidence of underlying lung disease or secondary due to pre-existing lung disease.”

    Spontaneous pneumothorax is a condition that is relatively rare in pediatrics. There is a bimodal age distribution – neonates and late adolescence. It is caused by tearing of the visceral pleural. Clinical signs include chest pain, dyspnea, tachycardia, tracheal deviation towards contralateral side, hypotension, cyanosis.

    There is a wide variation in treatment practices particularly for large pneumothoraces. For small ones, most are treated conservatively with or without oxygen therapy, and treatment for an underlying cause if present. Large pneumothoraces can be treated conservatively, by aspiration, chest tube, pleurodesis and/or surgery. The pneumothorax is seen on AP radiographs, but decubutus radiographs often make the pneumothorax more prominent. Because air will track anteriorly on a supine chest radiograph often used in small children, pneumothorax in these children can easily be missed on the AP but not on the decubitus radiograph.

    To review the complications of pneumonia and its common infectious disease causative agents, see What Are the Complications of Pneumonia?.

    Learning Point

    Causes of secondary spontaneous pneumothorax include:

    • Airway disease
      • Asthma, associated with
      • Bronchopulmonary dysplasia
      • Bronchiectesis
      • Cystic fibrosis
    • Congenital lung disease
      • Congenital lobar emphysema
      • Cystic adenomatoid malformation
    • Interstitial lung disease
      • Saroidosis
      • Langerhans cell histiocytosis
    • Infectious disease
      • Measles
      • Pneumonia or abscess
      • Pneumocystis jirovecii
      • Parasitic, especially ecchinococcal
      • Tuberculosis
    • Connective tissue disease
      • Marfan
      • Dermatomyositis
      • Ehler-Dahlos
      • Polymyositis
      • Systemic lupus erythematosis
    • Other
      • Catamenial pneumothorax or intrathoracic endometriosis
      • Foreign body
      • Malnutrition

    Questions for Further Discussion
    1. What is the pathophysiology behind treating with oxygen for pneumothorax?
    2. How should a recurrent pneumothorax be treated?

    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: Pleural Disorders

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

    To view images related to this topic check Google Images.

    Michel JL. Spontaneous pneumothorax in children. Arch Pediatr. 2000 Mar;7 Suppl 1:39S-43S.

    O’Lone E, Elphick HE, Robinson PJ. Spontaneous pneumothorax in children: when is invasive treatment indicated? Pediatr Pulmonol. 2008 Jan;43(1):41-6.

    Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009 Sep;10(3):110-7.

    Roberts D, Wacogne I. Question 3. In patients with spontaneous pneumothorax, does treatment with oxygen increase resolution rate? Arch Dis Child. 2010 May;95(5):397-8.

    Kurihara M, Kataoka H, Ishikawa A, Endo R. Latest treatments for spontaneous pneumothorax. Gen Thorac Cardiovasc Surg. 2010 Mar;58(3):113-9.

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

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    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

  • What Precautions Should Be Used for a Child Whose Parent is Hepatitis C Positive?

    Patient Presentation
    A 2-week-old male came to clinic with his parents for his health supervision visit. He had surpassed his birth weight by 10%. The parents voiced usual concerns, but the father also asked about anything special he should do because he himself had chronic Hepatitis C. He was an older father and had contracted it through a blood transfusion during a surgery as a teenager. He only knew about it several years later when he was told he could not donate blood. He was being monitored by his physician and his wife was Hepatitis C negative during pregnancy.

    The pertinent physical exam showed a healthy newborn with growth parameters in the 50-90% He had some erythema toxicum on his face. The diagnosis of a healthy newborn was made. The pediatrician wasn’t sure if there were specific recommendations for newborns and other children living in a family with a Hepatitic C positive parent. After looking at several articles online including recommendations from two professional groups in different countries, the pediatrician contacted the father. The infant had already had Hepatitis B vaccine and would receive additional doses plus Hepatitis A at the proper time. The father was told to be careful with any blood or body fluids that the child over time could come in contact with. He was also advised to not share toothbrushes or razors with the child as he grew. The pediatrician also recommended continued monitoring by the father and mother’s own physicians.

    Discussion
    Hepatitis C virus (HCV) is a single-stranded RNA Flavivus that was first identified in 1989 and universal screening in the blood supply was begun in 1992 in the United States. Overall incidence of acute HCV in children under age 19 is 0.1 per 100,000.

    In adults, the transmission is mainly from contaminated blood and body fluids, primarily intravenous drug use. It is the most common reason for liver transplantation in adults. Of those that acquire the acute infection, about 70% go on to become chronically infected. Adults have a slow progression of their disease with 20% having cirrhosis within 20 years. Being male, older, increased duration of infection, co-infections (particularly HIV and Hepatitis B), immunosuppression, hepatotoxic drug and alcohol use all increase the risk of cirrhosis. There is a 3-4% chance of hepatocellular carcinoma developing in chronic HCV patients with cirrhosis.

    In children the transmission is mainly vertical. Among family members, transmission is uncommon but inapparent or direct percutaneous or mucosal exposure to blood could occur. Of infants born to HCV-positive mothers, about 5-10% will acquire HCV. Of those that are acutely infected, only about 50-60% become chronically infected, and 25-75% of those will spontaneously resolve by 2-3 years of age. Unfortunately school age children and teenagers who acquire the infection have a natural history that is like adults. Most children who were infected at birth have no symptoms and may have normal, or elevated transaminases and viral levels. Long-term studies (10-20 years) show perinatally acquired HCV patients only have a 5-10% chance of significant fibrosis and < 5% develop cirrhosis.

    Testing is by specific immunoassays which detect IgG antibodies. Those for IgM are not available. Treatment recommendations are different for children infected through vertical transmission and older children and adults. Because younger children have a high spontaneous resolution rate, treatment may not be necessary particularly since there are side effects to the medications. Recommendations are also changing particularly in the adult populations as new medications are available and are studied more. Factors regarding treatment include: age, presumed transmission method, co-infection, genotype of HCV virus (type 1 is the most common in the US), and actual liver disease. Biomarkers for liver disease are available but are not as thoroughly developed and as useful in the pediatric population.

    Learning Point
    For families living with a HCV+ family member some general recommendations are advised. All patients should be vaccinated against Hepatitis A and B. HCV patients should also avoid hepatotoxic medications and excessive alcohol. Universal precautions with prompt treatment and clean-up of bloody wounds should be advised. There also should be no sharing of toothbrushes and razors. Breastfeeding is not contraindicated by a HCV+ mother. Patients who are HCV+ can go to a group-based childcare facility. For HCV+ people, changes in sexual practices are not recommended if a steady partner is maintained, but the partner should be informed of the risks and ways to prevent transmission. People with multiple sexual partners are recommended to use condoms and decrease the number of partners.

    Questions for Further Discussion
    1. When should infants be tested for HCV if their mother is HCV positive?
    2. What is the incidence of Hepatitis C in your local area?

    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: Hepatitis C

    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. Hepatitis C, 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; Accessed from the Internet on 3/6/13.

    Jhaveri R. Diagnosis and management of hepatitis C virus-infected children. Pediatr Infect Dis J. 2011 Nov;30(11):983-5.

    Porto AF, Tormey L, Lim JK. Management of chronic hepatitis C infection in children. Curr Opin Pediatr. 2012 Feb;24(1):113-20.

    Lagging M, Duberg AS, Wejstal R, Weiland O, Lindh M, Aleman S, Josephson F; Swedish Consensus Group. Treatment of hepatitis C virus infection in adults and children: updated Swedish consensus recommendations. Scand J Infect Dis. 2012 Jul;44(7):502-21.

    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.
    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.
    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.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • 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

  • How Often Does Clubfoot Recur?

    Patient Presentation
    A 5-year-old female was admitted to the inpatient service after a cuneiform to cuboid wedge surgery for recurrent talipes equinovarus on the left foot. The past medical history showed bilateral congenital clubfoot that was treated by the Ponseti method of serial casting and application of nightime foot orthosis for 2 years. Since that time the parents had noted an increase in left foot adduction and pain. The pertinent physical exam showed a healthy appearing female who was sleeping post-op. The left foot was in a plaster cast that had some sanguinous fluid on the cast at the heel. There was good capillary refill and mild swelling of the toes. The diagnosis of post-operative recurrent talipes equinovarus was confirmed. Overnight, the patient’s clinical course revealed that her pain was well-controlled with oral medication. The next day, physical therapy was able to get the patient up on crutches and she was sent home to followup in 6 weeks with orthopaedics.

    Case Image

    Figure 104 – AP radiographs of both feet show a persistent metatarsus adductus deformity in the left foot. There is a dysplastic appearing medial cuneiform bone with associated widening at the first tarsal-metatarsal joint.

    Discussion
    Newborn foot deformities are relatively common with an incidence of ~4.2%. About 75% of these are due to metatarsus adductus. Talipes equinovarus, calcaneovulgus foot and vertical talus are the other most common abnormalities.

    Congenital talipes equinovarus or clubfoot deformity occurs in 1-2/1000 births. The mneumonic CAVE identifies the major findings of Cavus, forefoot Adduction, hindfoot Varus and Equinus. Clubfoot can be mild to severe with the more severe forms being associated with other problems.

    The Ponseti method is currently considered the main treatment method with better short-term outcomes compared to other techniques. Dr. Ignatio Ponseti at the University of Iowa developed a technique of serial casting of the feet. Most patients require 5-7 casts changed weekly with longer treatment for more severely affected feet. A period of stabilization with ankle-foot orthoses (AFOs) is required to maintain the desired outcome. Sometimes a tendon transfer is also necessary.

    Learning Point
    Originally, Dr. Ponsetti had a 50% relapse rate with his early patients, but later this was decreased to 7% by overcorrection of the initial deformity with the initial casting and use of the night AFO splinting.

    Overall initial correction of deformity is as high as 93-100% of cases, but there can be persistent or recurrent deformity. Persistent deformity is one that has been incompletely corrected initially before being placed into the AFO. Recurrent deformity is one that was initially corrected, properly placed and maintained in the AFO, but recurs months to years later. Overall relapse rates range from 4-41%. Of patients that are compliant with AFO use, this is decreased from 0-21%.

    There are 3 main reasons for relapse:

    • Non-compliance with the AFO use – caregivers fail to understand the importance of consistent use of the AFO. Incidence of non-compliance with AFO use is 0-51%
    • Idiopathic
    • Increased risk – underlying disorder such as arthrogryposis, unrecognized or known neuropathy (e.g. Charot-Marie Tooth, myasthenia gravis, myotonic dystrophy, meningomyelocoele), and syndromes (e.g. Larsen syndrome).
      Non-idiopathic clubfeet have a higher rate of relapse; from 24-56% depending on the population.

    Treatment of relapse includes repeated casting and/or tenotomy, tibialis anterior tendon transfer and other surgical techniques depending on the specific area of deformity.

    Questions for Further Discussion
    1. What is the difference between calcaneovalgus foot and posteromedial bowing of the tibia?
    2. How is metatarsus adductus treated?

    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: Birth Defects and Foot Injuries and Disorders.

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

    To view images related to this topic check Google Images.

    Sankar WN, Weiss J, Skaggs DL. Orthopaedic conditions in the newborn. J Am Acad Orthop Surg. 2009 Feb;17(2):112-22.

    Jowett CR, Morcuende JA, Ramachandran M. Management of congenital talipes equinovarus using the Ponseti method: a systematic review. J Bone Joint Surg Br. 2011 Sep;93(9):1160-4.

    Gray K, Pacey V, Gibbons P, Little D, Frost C, Burns J. Interventions for congenital talipes equinovarus (clubfoot). Cochrane Database Syst Rev. 2012 Apr 18;4:CD008602. doi: 10.1002/14651858.CD008602.pub2.

    Chu A, Lehman WB. Persistent clubfoot deformity following treatment by the Ponseti method. J Pediatr Orthop B. 2012 Jan;21(1):40-6.

    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.
    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.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    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