What Causes Neck Stiffness?

Patient Presentation
A 14-year-old female came to clinic with a 3-day history of increasing neck stiffness. The pain was mainly left-sided and got worse as the day went on. She was also having generalized headaches in the evening that would resolve with sleep. She denied fevers, chills, nausea, emesis, or photophobia or other pain. She denied numbness or tingling in shoulders or arms. The past medical history showed that she was fully vaccinated and had 3 migraine headaches since the age of 12 that were controlled with sleep and ibuprofen. The family history was positive for migraine headaches and a paternal grandfather with a replaced knee. The review of systems was non-contributory.

The pertinent physical exam showed a female in no distress who was alert and oriented x 4. Vital signs were normal including temperature. HEENT was normal except for pain of the left trapezius and sternocleidomastoid muscles. This became worse with stretching of these muscles, but there was complete range of motion in the neck. Muscle palpation showed tense, spasmed muscles. The left occipitalis muscle also had some minor pain near the posterior insertion. Movement of the shoulder also caused mild pain when these muscles were engaged. Neurological examination was normal with good tone, strength and normal sensation in the face, neck, arm and shoulder. The diagnosis of muscle spasms of the left neck muscles was made. The physician noticed a large backpack in the room and asked the patient about it. She had started the school year that week and was carrying several large textbooks all day with her. She carried the backpack on her left shoulder only. The physician herself could barely lift the backpack, and talked with the patient about ways to decrease the weight (e.g. use online books if available, take only the books necessary at one time) and to wear the backpack on both shoulders or to use a pull-type, roller backpack on the ground if excessive weight was necessary. The patient was told how to use anti-inflammatory medications, heat and gentle exercise and massage to help eliminate the spasm. “You should be careful about your posture too.” she said. “People sitting in chairs or working at computers for a long time can make this worse. You need to get up and move frequently and stretch even for a minute. Then come back and do your work.”

Discussion
The complaint of neck stiffness always makes the clinician a little concerned until he/she understands the whole history because of the potential diagnosis of meningitis/encephalitis. While this potential is always concerning, there are many other causes of neck stiffness or pain to consider that are much more common. Normal wear and tear, injury or overuse that occur in daily activities and work can cause neck stiffness or pain. Often, even in adults, the cause of the pain is not recognized. Good examples are the adolescent above, or an innocent stumble, particularly if carrying something that may cause a person to be off-centered, twist their body to regain balance and only later cause a stiffness or soreness. The little stumble is not recognized as the cause of the neck stiffness.

Meningitis is an inflammation of the meninges. The most feared causes are rapidly growing bacteria such as meningococcus. Aseptic meningitis is usually caused by nonbacterial organisms and other diseases including enteroviruses, measles, mumps, and mycoplasma. Organisms colonize the person usually in the nasopharyngeal mucosa, spread to the blood stream and eventually reach the meninges by the blood-brain barrier and cerebrospinal fluid after evading the person’s immunological defenses. Lumbar puncture is needed to help determine if meningitis is present and the potential organism. To review what are the initial cerebrospinal fluid findings for meningitis, click here.

Meningismus that is associated with meningitis is neck pain with flexion of the neck, not lateral movement. In a seated upright position with the neck fully extended, the neck is flexed and resistance may be felt throughout the movement or just at the end of the movement.

Learning Point
The differential diagnosis of stiff neck includes:

  • Infectious
    • Abscess – retropharyngeal or peritonsilar
    • Lymphadenitis, cervical
    • Encephalitis
    • Meningitis
    • Discitis
    • Herpes zoster
    • Osteitis
    • Poliomyelitis
    • Tetanus
  • Neurological
    • Cerebral palsy
    • Epidural hematoma
    • Intracranial hemorrhage
    • Post-lumbar puncture
    • Vertebral anomaly
  • Arthritis – with prominent symptoms in the neck joints
  • Deconditioning or overuse of muscles
  • Drugs
  • Trauma to neck – whiplash where the muscles and ligaments are stretched with pain and inflammation
  • Torticollis – spasm of the sternocleidomastoid muscle or hemorrhage
  • Tumor – primary or metastatic

Questions for Further Discussion
1. What bacterial organisms cause meningitis?
2. How much weight is recommended to be carried in a backpack?
3. What are indications for radiological evaluation of a patient with neck stiffness?

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: Neck Injuries and Disorders

.

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

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Sheldon SH, Levy HB. Pediatric Differential Diagnosis. 2nd Edit. Second Edition. Raven Press: New York. 1985:153-154.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:250-252.

Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010 Nov;126(5):952-60.

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.

    Author

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

  • What are the Most Common Motor and Vocal Tics?

    Patient Presentation
    A previously healthy 10-year-old female came to clinic with new onset of eye blinking that the mother had noticed for 2 weeks. The patient initially didn’t notice it, but was becoming more aware and said that she noticed it occurred more when she was upset or excited. Her friends had not noticed it. The eye blinking didn’t seem to bother her in general and the mother said that she saw only increased eye blinking in the evenings particularly when she was tired. They both agreed that she was only having eye blinking and denied any abnormal motor or vocal movements despite extensive examples. The patient denied any visual changes, photophobia, changes in tearing, or erythema of the eye structures. The past medical history was positive for seasonal allergic rhinitis, but the patient was not having any other allergic symptoms. The family history was positive for eye blinking and cheek puffing tics in her mother as a child that resolved before middle school. There was no neurological, psychiatric or school problems in the family. The review of systems was negative.

    The pertinent physical exam showed a cooperative female with increased eye blinking throughout the examination. Her growth parameters were at the 90%. Her vital signs were normal. Visual acuity was 20/25 in the left eye and 20/20 in the right. Eye examination was normal as was the rest of her examination. The diagnosis of a simple or provisional motor tic was made. The family was counseled that most of these resolve within a few weeks to months, but it could be persistent. It could also herald the beginning of other tics. As the current tic was not bothering her, the family was told to continue to monitor it and if it became more of a problem or if more complex motor or vocal movements began, to contact the office. The patient’s clinical course showed an increase in the eye blinking for about 2 months, then it resolved. At two years later she had no other tics.

    Discussion
    Tics are usually single repetitive, non-rhythmic, non-purposeful movements or utterances. Tics can be multiple and complex however. Tics may be preceeded by a premonitory urge where the person has a feeling that a certain type of tic is going to occur and then this feeling goes away after the tic is produced.

    Tics, especially simple motor tics, are very common with ~10-15% of elementary age children having a tic at some time. In one community-based study, the overall prevalence was 3-9% with an overall frequency of 24% of elementary school children during one school year. Tics are more common in boys and present around age 6-12 years, but may be not recognized until as late as 21 years. They are usually most severe around 10-12 years of age. Motor tics usually appear 2-3 years before vocal tics but vary with the individual. Tics can last for a few weeks, months or be chronic (> 1 year of symptoms). Simple tic or provisional tics last less than 1 year. Chronic or persistent tics last more than 1 year. Note that the definitions are based on timing of symptoms not the severity or the complexity of the tics themselves.

    Tourette syndrome (TS) is a particular type of tic but for the lay public may be the most well known. It is a chronic tic disorder where patients have both motor and vocal tics, although these may occur at different times. Patients with TS also have psychiatric symptoms such as obsessive-compulsive disorder, attention deficit disorder, depression, anxiety and others. Patients often have complex tics. The tics must have started before age 18 and they cannot be due to medications or other medical conditions to be diagnosed with TS.

    Treatment is education and watchful waiting mainly with patients with complex, chronic or tics that are disturbing using a variety of alpha-2 agonists, anti-psychotics and botulinum toxin. Habit reversal training or different types of electrical brain stimulation have also been used.

    The prognosis in most children is generally good with resolution for many patients. Unfortunately, despite research at this time, there are no specific predictive signs, symptoms or tests which can determine the prognosis for an individual.

    The differential diagnosis of other involuntary movement disorders includes:

    • Chorea and choreoathetosis
    • Hiccough
    • Myoclonus
    • Reflexes – Moro, startle
    • Spasmus nutans
    • Tics
    • Tremor
    • Torticolis, spasmodic
    • Torsion spasms
    • Other
      • Ballismus
      • Hysteria
      • Rett syndrome
      • Stereotypical movements with autism

    Learning Point
    The most common motor tics involve the face and head with ocular tics being particularly common. The most common vocal tics are throat clearing and sniffling which can be misdiagnosed as allergic symptoms or asthma. Patients with Tourette Syndrome (TS, discussed above) and those with other types of tics have other unusual behaviors such as echolalia (repeating someone else’s words), pallilalia (repeating one’s own words), coprolalia (obscene speech), echopraxis (repetitive gestures), copropraxis (obscene gestures), and coprographia (obscene writing). These behaviors are considered complex tics.

    Questions for Further Discussion
    1. What is PANDAS and how is it related to tics?
    2. What is the Yale Global Tic Severity Scale?

    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: Movement Disorders and Tourette Syndrome.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Illingworth RS, Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:227-234.
    Snider LA, Seligman LD, Ketchen BR, et. al. Tics and Problem Behaviors in Schoolchildren: Prevalence, Characterization, and Association. Pediatrics. 2002;110;331-336.

    Shprecher D, Kurlan R. The management of tics. Mov Disord. 2009 Jan 15;24(1):15-24.

    Siniatchkin M, Kuppe A. Neurophysiological determinants of tic severity in children with chronic motor tic disorder. Appl Psychophysiol Biofeedback. 2011 Jun;36(2):121-7.

    Ludolph AG, Roessner V, Munchau A, Muller-Vahl K. Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Dtsch Arztebl Int. 2012 Nov;109(48):821-288.

    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.

  • 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.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

    Author

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

  • What Are Precautions for Someone Traveling to the Middle East About the Risk of MERS?

    Patient Presentation
    Ten and twelve-year-old male siblings came to clinic before traveling from the United States to visit relatives in Jordan for 6 weeks. The children were healthy, had current routine vaccinations and had traveled to Jordan 5 years previously. They were visiting major cities and did not plan to visit rural locations or farms. The family was transferring planes in Europe during the visit. The mother was concerned because of the recent media coverage of MERS (Middle East Respiratory Syndrome) in the United States, and wanted to know what she should do about the trip. The pertinent physical examinations revealed healthy boys.

    The diagnosis of healthy males was made. The pediatrician confirmed that the boys were fully vaccinated. In the room, he then used the Centers for Disease Control website to look at the specific travel recommendations for Jordan. The boys had previously had typhoid vaccine but because of the time lapse oral typhoid vaccine was prescribed. The risk of rabies was considered small so they did not receive that vaccine. For MERS, the physician discussed that the illness presented with common upper airway symptoms such as fever, cough and shortness of breath. The World Health Organization had increased its alert level and was issuing alerts for travelers to be more aware, and use standard precautions such as hand hygiene and covering coughs more consistently. The physician printed the information for the family and told them to monitor their health closely during and after the visit. If they had any concerns they should seek help in Jordan or call his office promptly after they returned. The physician also noted that although it was not exactly clear how the virus was spread there were clusters of patients who were health care workers. The mother said that none of the family they were staying with were health care providers, but were business and service workers. Nonetheless, the physician recommended using hand sanitizers, washing hands, and common sense at all times.

    Discussion
    Middle East Respiratory Syndrome (MERS) is a respiratory illness cause by a coronavirus called MERS-CoV. It was first reported in Saudi Arabia in 2012. People with confirmed cases of MERS have developed severe respiratory illness that includes acute onset of cough, shortness of breath, and fever. Other symptoms include gastrointestinal symptoms such as diarrhea. Pneumonia is common, and patients may progress to respiratory failure. Other end organ failure has occurred, particularly kidney failure and septic shock. The death rate is up to ~30% currently. People with compromised immune systems are more at risk.

    The exact transmission is not known but it has been shown to spread between people who are in close contact, from infected patients to health care personnel, and there some clustered cases in specific countries. There is no evidence of sustained spreading in community settings. All of the cases to date have been linked to countries in the Arabian Peninsula. The virus has been linked to bats and camels but it is unknown exactly how it is spread between or within species. MERS is different than the SARS virus that was identified in 2003 but both are caused by coronaviruses and have been linked to bats.

    Health care providers should be alerted to patients who have traveled to the Arabian Peninsula and surrounding countries within 14 days of travel. People who transited within airports but did not enter the country are not considered at increased risk. Although more common causes of respiratory illness such as influenza are still more common, the risk of MERS should be considered. Vigilant appropriate precautions including consistent use of personal protective equipment should be instituted for health care providers.

    A patient with an unexplained respiratory illness that meets the following criteria should be reported to the Centers for Disease Control:

    A patient with “Fever (> or equal to38°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiologic evidence)
    AND EITHER
    History of travel from countries in or near the Arabian Peninsula[a] within 14 days before symptom onset
    OR
    Close contact[b] with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula[a]
    OR
    Is a member of a cluster of patients with severe acute respiratory illness (such as fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments

    “[a]Countries in the Arabian Peninsula and neighboring countries: Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Palestinian territories, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen.
    [b]Close contact is defined as a) any person who provided care for the patient, including a health care worker or family member, or had similarly close physical contact; or b) any person who stayed at the same place (lived with or visited) as the patient while the patient was ill.

    Learning Point
    Public health officials recommend educating the traveling public to the increased risk of MERS and for them to consistently use general public health practices such as hand hygiene, covering coughs, disposing of tissues, and avoiding contact with ill individuals. Patients should monitor their health for acute onset of febrile respiratory illnesses for 14 days after traveling to the Arabian Peninsula.

    Questions for Further Discussion
    1. How is MERS different than H1N1 virus?
    2. Name other zoonotic viruses?
    3. Where can you find current pubic health traveler advisories?

    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: Coronavirus Infections and International Health.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Centers for Disease Control. Middle East Respiratory Syndrome (MERS).
    Available from the Internet at http://www.cdc.gov/CORONAVIRUS/MERS/INDEX.HTML (rev. 5/15/14, cited 5/16/14).

    Centers for Disease Control. MERS in the Arabian Peninsula.
    Available from the Internet at http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-arabian-peninsula-uk (rev. 5/12/14, cited 5/16/14).

    Centers for Disease Control. Middle East Respiratory Syndrome (MERS) Frequently Asked Questions.
    Available from the Internet at http://www.cdc.gov/coronavirus/MERS/faq.html (rev. 5/12/14, cited 5/16/14).

    World Health Organization. Frequently Asked Questions on Middle East Respiratory Syndrome Coronavirus (MERS-CoV)
    Available from the Internet at http://www.who.int/csr/disease/coronavirus_infections/faq/en/ (rev. 5/9/14, cited 5/16/14).

    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.
    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
    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.

  • 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.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

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

    Author

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

  • His Weight Gain is Slowing Down

    Patient Presentation

    A 6-month-old male came to clinic for his health supervision visit. His parents had several questions about when he would start crawling and saying full words. They became more concerned when they saw the actual numbers of his weight gain since his 4 month appointment because they had had the sense that he was “slowing down” in his growth. He was breastfeeding every 4 hours for 20 minutes and they had started some cereal with iron in the past month. The past medical history showed a previously healthy, full-term infant with normal growth and development to date. The pertinent physical exam revealed an interactive infant who easily grabbed objects, sat by himself, said consonants and was rolling over. His vital signs were normal. His head circumference and length were consistently about 50%. His weight was slowly decreasing from the 50% at 2 months of age to between the 25%-50% currently. His examination was normal.

    The diagnosis of a healthy male was made with normal growth and development. Although the resident had tried to educate the family that this was normal, the parents were still concerned when the attending physician came to see the infant. She reiterated what the resident had said and when showing the family the growth chart, pointed out the sharp vertical slope during the first 3 months of life, and how the growth curve slope changed over time. She said, “If your son keeps growing at the rate he was in the first few months of life, he is going to be Dad’s size when he is 2 years old.” She went on to say, “I know that seems kind of crazy, but I’ve actually done the calculations and its true, so he has to slow down how fast he’s growing.” She also discussed how in his case, the small, slow difference of being at the 25-50% currently was normal. “We’re also going to continue to watch how he grows and develops. If at any time you are concerned about his weight, just come back and we’ll re-weigh and measure him.” The parents seemed happy with the explanation, but afterwards the resident was skeptical about the growth rates. The attending and resident did a couple of sample calculations between seeing patients that day and the resident was then convinced about the growth rates.

    Case Image

    Discussion
    Since growth is such an important indicator of health in infants and children, parents are appropriately concerned that their children are growing well. A common concern for parents is that the child began at a certain percentile and is crossing growth percentiles but at a normal rate (i.e. moving toward their genetic potential). Some other parents believe that “fat babies” are healthy babies and want to see children growing at the top of the growth charts. Even if they do not believe in the “fat babies” idea, many families of children who are at the normal lower percentiles of the growth chart are worried that their child is not gaining enough weight. A careful review of the growth charts and parental education usually can assuage the concerns for most families.

    Learning Point
    Many parents will notice the normal changes in the growth rates of children particularly over the first 12 months of life, and will raise questions such as the parent above. Again careful review and explaining this normal phenomenon to parents in a way that they can comprehend usually helps the family to understand that their child is normal.

    Newborn and young infants are growing at fantastic rates, almost so much that it is difficult to comprehend the rate. However if these infants were to continue growing at these rates, they would be too large much too soon. Therefore there must be a normal decrease in the growth rate such that the child continues to grow but more slowly. In the figure below, using a starting weight of 3.35 kg (50% for males) and the growth rate for an individual month, the predicted weight that a male infant would have attained was calculated at 2 and 5 years later. Weight gain was assumed to be compounded monthly.

    Using the rate of weight gain between 2-3 months (= 14.5%), the infant would be around the size of an adult male by age 2 or 86.7 kg! This is obviously too great a weight gain for a normal infant. Using the weight gain rate at 6 months of age (=5.64%), the infant would be around 12.5 kg at 2 years of age, which is about the normal average weight of a male infant at that age (= 12.1 kg). And using the weight gain rates at 12 and 24 months of age, the infant would only be 6.1 kg and 5.0 kilograms at 2 years. Obviously this is too small a weight gain for a normal infant. Thus, one can see why there are normal decreases in weight gain rates particularly around 3 and 6 months of life. A growth chart is available to review here,

    Not only is it imperative that the weight gain slow for the infant’s own health, but also for the mother. A breastfeeding mother would need to produce ~66,000 calories or ~940 liters of breastmilk to supply only the weight gain of the infant who was growing at the 3 month old rate over 2 years. This is about an additional 90 calories and 3 liters of fluid/day for the mother to consume that solely would be going toward the weight gain of the infant.

    Questions for Further Discussion
    1. How do the weight gain rates for premature infants compare to normal weight infants?
    2. How do you determine mid-parental height? see How Do I Calculate Mid-Parental Height and Other Growth Parameters?

    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: Child Development and Growth Disorders.

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

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Centers for Disease Control. Data Table for Boys Length-for-age and Weight-for-age Charts.
    Available from the Internet at http://www.cdc.gov/growthcharts/who/boys_length_weight.htm (rev. 9/9/10, cited 4/30/14).

    DePaul University, Quantitative Reasoning Center. Compound Interest Formula. Medscape.
    Available from the Internet at https://qrc.depaul.edu/StudyGuide2009/Notes/Savings%20Accounts/Compound%20Interest.htm (rev. 2009, cited 4/30/14).

    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.

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

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    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