What is in the Differential Diagnosis of Purpura?

Patient Presentation
A 2.5-year-old male came to clinic because of a new onset rash. The child had cold symptoms 2 weeks previously that had improved. He again began to have some rhinorrhea 2 days ago but was afebrile and otherwise well. That morning he awoke with a bright red rash on his extremities, trunk, buttocks and face that was slightly pruritic. His mother denied new soap/lotions, skin products, medications or complementary and alternative products or treatments. He was drinking well but eating less. There were several children at the daycare he attended who had recent colds. The past medical history showed a generalized rash to amoxicillin. The family history was negative for any autoimmune or kidney disease. The review of systems was otherwise normal.

The pertinent physical exam revealed normal vital signs including a temperature of 99.3°, blood pressure of 78/58, and growth parameters in the 5-15%. HEENT showed clear rhinorrhea. Lungs were clear. Extremities had no edema. His skin had bright red, uniform lesions that were generally well-demarcated without central clearing. The lesions were 1 cm with a great deal of coalescence. Some on the lower extremities felt slightly raised. The lesions were located on the face, extremities, buttocks and trunk and spared the scalp, genitals, hands, feet and intertrigenous areas. He had no mucous membrane involvement including his urethra. The diagnosis of a viral exanthem was made and the mother was instructed to monitor the child. She was told that it was possible that the pruritus could get worse and diphenhydramine could be used, as well as acetaminophen for discomfort.

The patient’s clinical course showed that on the early evening of the next day, the mother called because the boy’s rash on his legs was now purple and his feet had become swollen earlier in the day. She denied any other changes as to where the rash was located or how it looked other than that it was darker and more purplish. It was not “bumpier.” She denied any new “dots,” bleeding, oral lesions, eye changes, or edema of the face or hands. He continued to be afebrile, eating and drinking well. She had given him one dose of diphenhydramine earlier in the day. He had been acting normally during the day. The pediatrician who had seen the child was on call that evening and thought that this possibly could be Henoch-Schönlein purpura, but as the child was well, was drinking and urinating well, and had had a normal blood pressure the day before, he recommended to monitor closely the child for any changes and see the child the next day. The following day, the rash had begun to fade and was less pruritic. His blood pressure was normal. The purple changes that the mother had described were reproduced in the clinic when the child sat down. The lesions near the buttocks had a slightly darker hue to them that resolved when the child stood up. He had no edema on physical examination. The rash continued to fade over the next 2-3 days.

Discussion
Children presenting with rashes are common but certain characteristics may be concerning such as descriptions of petechiae or purpura. Purpura are characterized by non-blanching skin lesions between 3-10 mm in size that are caused by bleeding into the skin. Usually they are reddish-purplish hence the name purpura coming from the Latin word. Non-blanching lesions that are 10 mm are ecchymosis.

Henoch-Schönlein purpura (HSP) is a generalized vasculitis that commonly involves the gastrointestinal tract, kidneys, skin and joints, and is especially seen in children 2-11 years old. Classically HSP presents with purpura of the lower-extremities (or other dependent areas), migratory polyarthritis, colicky abdominal pain, and renal disease. A macular-papular or urticarial rash can precede the purpura, but generally resolves within 24 hours such as the one above. Peripheral edema can occur because of the renal involvement. Its etiology is uncertain but is probably multifactorial with antigens, environmental and genetic factors. It is thought to be caused by an unknown antigen stimulating a rise in IgA producing and antigen-antibody complexes being deposited locally in the body and activating pathways leading to necrotizing vasculitis. Associations with bacteria, viruses, vaccinations and drugs have been reported. Most children have complete recovery but serious renal and gastrointestinal complications may occur.

Learning Point
The differential diagnosis of purpura includes:

  • Acute hemorrhagic edema of infancy – For more information about AHEI click here.
  • Acute streptococcal glomerulonephritis
  • Blood clotting disorders
  • Drugs – particularly which may cause fragile blood vessels or platelet problems
  • Hemolytic-uremic syndrome
  • Henoch-Schönlein or anaphalactoid purpura – for more information about HSP click here.
  • Hypersensitivity vasculitis
  • Hypertension – malignant, pre-eclampsia and similar gestational problems
  • Immune thrombocytopenic purpura
  • Infection
    • Disseminated intravascular coagulation / Sepsis
    • Purpura fulminans from Neisseria meningiditis
    • Congenital infections such as cytomegalovirus and rubella
    • Rickettsial diseases
  • Polyarteritis nodosa
  • Thrombotic thrombocytopenic purpura
  • Scurvy
  • Urticarial vasculitis
  • Trauma

Questions for Further Discussion
1. What causes urticaria?
2. What are the potential complications of HSP?
3. What are criteria for referral to a dermatologist?

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: Platelet Disorders and Vasculitis.

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.

Weiss PF. Pediatric vasculitis. Pediatr Clin North Am. 2012 Apr;59(2):407-23.

Rigante D, Castellazzi L, Bosco A, Esposito S. Is there a crossroad between infections, genetics, and Henoch-Schonlein purpura? Autoimmun Rev. 2013 Aug;12(10):1016-21.

Mathur AN, Mathes EF. Urticaria mimickers in children. Dermatol Ther. 2013 Nov;26(6):467-75.

Roberts PF. Henoch-Schonlein Purpura. EPocrates Online. Available from the Internet at https://online.epocrates.com/u/2935110/Henoch-Schonlein+purpura/Diagnosis/Differential (rev. 7/8/13, cited 3/11/14).

MedlinePlus Encyclopedia. Purpura. Available from the Internet at http://www.nlm.nih.gov/medlineplus/ency/article/003232.htm (rev. 4/24/13, cited 3/11/14).

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.
    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.

  • 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.

  • 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 is Pectus Carinatum Treated?

    Patient Presentation
    A family medicine physician contacted the on-call pediatrician about a 14-year-old male who was worried about his diagnosis of pectus carninatum. He had always had a prominent anterior chest but it had become more pronounced during puberty and he was now very self-conscious. The family medicine physician wanted to know when it was appropriate to refer to a surgeon and if the surgery staff at the regional children’s hospital did surgeries for this problem. The pediatrician said that she knew that there were open- and closed- surgical procedures for the problem and also thought that bracing was an option but she herself hadn’t treated anyone with this problem recently. The pediatrician recommended referring to the surgical services at the hospital. She also suggested considering some psychological support services for possible anxiety and body image problems the patient may be having. The family medicine physician said that he had already suggested the psychological services to the family and they were considering doing it. He was going to send the patient to the surgeons.

    Discussion
    Pectus carinatum (PC) is the second most common congenital chest wall deformity after pectus excavatum. It presents usually in early adolescence around puberty, most commonly in males (4:1) and occurs 1 time in every 2500 persons. There are two common variants of the sternum and adjacent costal cartilages protrusion: chondrogladiolar (the body of the sternum protrudes, ie the gladiolus), and chondromanubrial (the superior part of the sternum protrudes). There can also be a mixed variant where the manubrium protrudes and the gladiolus is depressed. Most patients have symmetric deformities but they can be unilateral.

    The etiology is unknown but felt to be due to abnormal costal cartilage growth. A positive family history is found in ~25% of patients and PC is associated with Marfan and Noonan syndromes. Patients usually present during the adolescent growth spurt and usually have no other symptoms than the protruding chest. Sometimes patients can complain of chest wall discomfort particularly when lying prone. Heart palpitations or respiratory symptoms are unusual. The more common problems are disturbed body image and inability to wear clothing (particularly bras in females) with resulting decreased quality of life. The evaluation mainly is the history and clinical physical examination. Plain chest radiographs are usually enough to plan surgeries if needed. Patients with other symptoms or with mixed variations may need a cardiac evaluation and/or pulmonary function testing.

    Click here to learn more about pectus excavatum.

    Learning Point
    Once puberty has stopped, the PC progression is minimal. Age, pubertal status and chest wall flexibility helps determine the treatment options which are usually:

    • Watchful waiting and support – Many patients and families choose this option once they understand the natural history. Pectoral muscle strengthening can also be used help change the chest contour and make the PC appear less noticeable.
    • External bracing – This is the treatment option usually recommended for pre-pubertal and pubertal adolescents as it is non-invasive. The side effects are skin irritation and it is effective. There are multiple regimens but generally the bracing needs to be used multiple hours a day and for many months. Bracing is often continued until puberty has ceased.
    • Surgery – The Ravitch procedure (osteotomy and costal cartilage resection) and its variations have been used for more than 50 years. The Nuss procedure (stainless steel bar is used to compress the chest wall) is also used. The Nuss procedure has the advantage of being a minimally invasive technique and thus has aesthetic advantages.

    Questions for Further Discussion
    1. How is pectus excavatum treated?
    2. Besides pectus excavatum and pectus carinatum, what other chest wall deformities are there?
    3. List different cartilage disorders.

    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: Cartilage Disorders and Chest 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.

    Blanco FC, Elliott ST, Sandler AD. Management of congenital chest wall deformities. Semin Plast Surg. 2011 Feb;25(1):107-16.

    Obermeyer RJ, Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin North Am. 2012 Jun;92(3):669-84, ix.

    Desmarais TJ, Keller MS. Pectus carinatum. Curr Opin Pediatr. 2013 Jun;25(3):375-81.

    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.
    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.

  • 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

  • What Treatment is Available for Lymphatic Malformations?

    Patient Presentation
    A full-term newborn female was born with a mass over her left lower back. The past medical history showed that she was born to a 22 year old G1P1 female with an uneventful pregnancy including a normal prenatal ultrasound. Delivery was uncomplicated except for the previously unrecognized mass. She had voided and stooled soon after birth. The family history was negative for neurological or genetic conditions. A maternal aunt had one spontaneous abortion early in pregnancy but had 2 other normal children.

    The pertinent physical exam showed a well appearing female with normal vital signs and growth parameters in the 25-50%. Ballard examination was consistent with a 39-40 week infant. The left lower back had a skin-covered sac measuring 15 x 7.5 cm that crossed the midline and displaced the gluteal cleft. There was a positive fluid wave. She was not bothered by the mass. She had a normal neurological examination and was moving all her extremities well and had normal strength and tone. She had no other stigmata of genetic syndromes. The differential diagnosis of a meningomyelocoele (unlikely because of normal neurological examination), arteriovenous or lymphatic malformation, teratoma, lipoma or dermoid cyst were considered. Less likely was an abscess. Her laboratory evaluation was normal including a complete blood count with no anemia or thrombocytopenia. The radiologic evaluation of a magnetic resonance imaging scan showed weighted MR images of the lumbar spine show a large soft tissue mass composed of large cysts that was most compatible with a lymphatic malformation.. The patient’s clinical course included consulting pediatric surgery and pediatric neurosurgery. After the radiology results were known, the pediatric surgeons decided to attempt sclerosis of the lesion. This decreased the lesion in size to ~5 x 5 cm lesion that was later resected without difficulty.

    Case Image

    Figure 111 – Axial T1 (top), T2 (middle) and T1 with contrast (bottom) weighted MR images of the lumbar spine show a large soft tissue mass in the subcutaneous tissues of the left back that is composed of large cysts (best appreciated on the T2 weighted images) separated by thin septations which enhance mildly after the administration of contrast. The findings were most compatible with a lymphatic malformation.

    Discussion
    Vascular malformations including those of the arterial, venous and lymphatic systems are due to an arrest of the normal process of angiogenesis, vasculogenesis and remodeling of the vessels. They are not tumors and need to be differentiated from benign and malignant vascular lesions. They occur in 1.5% of the population with 90% present at birth.

    The nomenclature of congenital lymphatic malformations can be confusing. They can be present in any location and may have mixed elements within them (i.e. lymphatic and venous, lymphatic and arterial, etc.) and different structural components such as dilatation or hyperplasia. Thus people will use different wording that can be ambiguous or incorrect. Lymphatic malformations and problems can be acquired also usually secondary to trauma or surgery with problems arising in the adjacent tissues. An example in the adult population is lymphedema after breast surgery and in the pediatric population is a chylothorax after congenital open-heart surgery.

    Cystic hygromas or true congenital lymphatic cysts, are lymphatic malformations that have normal development of the lymphatic system but do not establish the normal communication with the venous system. These can occur anywhere in the body but occur often in the head and neck, many times on the left side. Some cystic hygromas are associated with chromosomal abnormalities particularly Turner’s syndrome.

    Lymphatic malformations may be seen in various syndromes including Down, Gorham-Stout, Hennekam, Klippel-Trenaunay, Noonan, Proteus, and Turner syndromes. Complications include compromise and obstruction of surrounding tissues and structures such as airway or visual compromise, bony changes including overgrowth or various limb discrapencies or dental malocclusions, content leakage with ensuing ascites or effusion, infections, bleeding, and lymphopenia. Radiologic evaluation can include ultrasound, computer tomography, magnetic resonance imagining, or magnetic resonance lymphangiography in some institutions.

    Learning Point
    Treatment is multi-modal with teams of professionals often involved including surgeons and surgical subspecialties, pediatric subspecialties such as neonatology or gastroenterology, radiology, dental, genetics, physical therapy, nutrition, psychology, and social work. The patient’s specific lymphatic malformation and location will dictate the necessary professional involved. Specific treatment includes supportive care (e.g. compression stocking, custom-made shoes, etc.), sclerotherapy, and surgical including management directly of the lesion and other treatment such as paracentesis, tracheotomy, and reconstructive surgeries. Medical treatment is also available using interferon or octreotide.

    Questions for Further Discussion
    1. What is in the differential diagnosis of a neck mass?
    2. What are physical examination signs in patients with Turner syndrome or Klippel-Trenaunay syndrome?
    3. What are indications for a genetics consult in a patient with a suspected vascular malformation?

    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: Lymphatic Diseases and Birth Defects.

    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.

    Blei F. Congenital lymphatic malformations. Ann N Y Acad Sci. 2008;1131:185-94.

    Gloviczki P, Duncan A, Kalra M, Oderich G, Ricotta J, Bower T, McKusick M, Bjarnason H, Driscoll D. Vascular malformations: an update. Perspect Vasc Surg Endovasc Ther. 2009 Jun;21(2):133-48.

    Liu NF, Lu Q, Yan ZX. Lymphatic malformation is a common component of Klippel-Trenaunay syndrome. J Vasc Surg. 2010 Dec;52(6):1557-63.

    Liu NF, Yan ZX, Wu XF. Classification of lymphatic-system malformations in primary lymphoedema based on MR lymphangiography. Eur J Vasc Endovasc Surg. 2012 Sep;44(3):345-9.

    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.

  • 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

  • How Does Pediatric Psoriasis Present?

    Patient Presentation
    A 14-year-old male came to clinic with a history of a new scalp lesion that had been present for 2 weeks. He had recently seen his barber who noticed the lesion and thought that it was psoriasis. The patient had not tried any treatment. He denied any new soaps, lotions, shampoos, acne or other skin or makeup products. He denied pain, pruritus or burning. The past medical history showed that he had scalp and facial seborrhea as an infant that lasted until 15 months of age. He occasionally had a dry scalp and needed to use a general dandruff shampoo in the winter. He also has general xerosis that was controlled by emollients. The family history was positive for atopic dermatitis. The review of systems showed he was healthy with no fevers, weight loss, arthralgias or infections.

    The pertinent physical exam showed a healthy male with growth parameters in the 75-95%. The left parietal area had a 2.5 cm round lesion with thick yellow, greasy scale. There were no broken hairs or alopecia. There was mild erythema but no edema of the area. He had generalized xerosis, but no changes to his nails or umbilicus. The diagnosis of seborrhea was made. The patient was started on a topical steroid and a general selenium sulfide-containing dandruff shampoo to assist with the scale.

    The patient’s clinical course over the next 3 weeks revealed that he had improvement but not complete resolution. There was no erythema and markedly decreased scale. He was changed to a tar-containing shampoo along with continued steroid therapy. Three weeks later, he had continued improvement but again not resolution and was referred to a dermatologist. The dermatologist performed a skin scraping confirming that this lesion was not tinea capitus and agreed that this was seborrhea. He was changed to a lotion-based steroid cream and a salicylic acid-containing shampoo. The lesion resolved over the next 6 weeks.

    Discussion
    Psoriasis is an inflammatory skin disease that is chronic and relapsing with periods of remission. It occurs in genetically susceptible persons and is felt to be triggered by environmental factors including infection (especially Group A, β-hemolytic streptococcus), emotional and physical stress, and skin irritation including friction, rubbing, pressure and scratching. It is common in patients with certain HLA types including HLA-Cw*0602, HLA-Cw6, IL-15 plus others.

    It occurs in about 1% of the general population with two age-onset peaks: 16-22 years and ~60 years, but can occur at any age. Some studies show differences with girls/women more affected (2:1 over boys/men) and other studies do not support gender differences. Pediatric psoriasis patients are more likely to have a family history of psoriasis than adults.

    Diagnosis is by clinical features and/or skin biopsy. Treatment is multimodal with education and psychosocial support being important component of this chronic disease. Many treatments in the US are used “off-label” in pediatric patients as they are not approved by the Federal Drug Administration for psoriasis in the pediatric age group. Treatment includes topical, phototherapy, and systemic treatment. Topical treatments include corticosteroids, calcineurin inhibitors, coal tar, keratolytics, retinoids, Vitamin D3 analogs and anthralin. Phototherapy with UVA and UVB can be used in various manners. Systemic treatments include cyclosporine, methotrexate, erythromycin, and various tumor-necrosis factors.

    The general differential diagnosis of psoriasis includes:

    • Atopic dermatitis
    • Contact dermatitis
    • Pustular rashes
    • Pitarysis
    • Seborrhea
    • Tinea

    In specific locations many other diagnoses may be included such as squamous cell carcinoma, oncomycosis, and blepharitis.

    Learning Point
    Common subtypes of pediatric psoriasis include:

    • Plaque
      • Silver-scaled, well-demarcated plaques
      • Usually on knees and elbow extensor surfaces but can occur in any skin area
      • This is the most common subtype – 34-84%
    • Scalp
      • If only occurring on scalp, may present with mild greasy and scaly plaques
      • Alopecia may be present
      • May be the site of initial presentation in 50% of patients
    • Face
      • Is more commonly involved with pediatric psoriasis than adult psoriasis
    • Diaper
      • Occurs in infants
      • Can occur in disseminated psoriasis
    • Guttate
      • Multiple, small, scaly papules
      • Occurs on extremities, trunk and sometimes face
      • Often triggered by Group A, β-hemolytic streptococcus
    • Pustular
      • Multiple papules occurring on erythematous skin
      • Papules may be localized or generalized
      • Papules are sterile
      • Often occurs with onset of fever and arthralgias

    Other physical findings associated with psoriasis include nail pitting or other changes, mucosal ulcerations, geographic tongue and arthritis.

    Questions for Further Discussion
    1. What are the presentations of psoriatic arthritis?
    2. What are the potential side effects of topical steroids?
    3. What are the potential side effects of systemic treatment of psoriasis for pediatric patients?

    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: Psoriasis.

    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.

    Bard S, Torchia D, Schachner LA. Managing pediatric patients with psoriasis. Am J Clin Dermatol. 2010;11 Suppl 1:15-7.

    Sticherling M, Augustin M, Boehncke WH, Christophers E, Domm S, Gollnick H, Reich K, Mrowietz U. Therapy of psoriasis in childhood and adolescence – a German expert consensus. J Dtsch Dermatol Ges. 2011 Oct;9(10):815-23.

    Shah KN. Diagnosis and treatment of pediatric psoriasis: current and future. Am J Clin Dermatol. 2013 Jun;14(3):195-213.

    Meffert J. Psoriasis. Medscape. Available from the Internet at http://emedicine.medscape.com/article/1943419-differential (rev. 1/21/14, cited 2/21/14).

    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.
    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.

    Author

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