Can You Help Me? I Don’t Remember All Those Brain Malformations?

Patient Presentation
An internist came by the general pediatric clinic to ask for help because he was seeing a young adult patient in his internal medicine clinic who had a history of an incidentally found Chiari I malformation that had been asymptomatic.
The patient currently was complaining of some new headaches and he wondered if he should be worried about the malformation as a potential cause.
The pediatrician reviewed with him that Chiari I malformations are considered congenital with caudal displacement of the cerebellar tonsils.
Patients are often asymptomatic but if symptoms occur they generally occur in adolescence or early adulthood.
The internist was going to evaluate the patient and possibly discuss his findings with one of the neurologists.


Figure 47 – Sagittal FLAIR-weighted image of the brain reveals the tip of the cerebellar tonsils to be 12 mm below the level of the foramen magnum and therefore to be low lying in position. If the tip of the cerebellar tonsils is greater than 3-5 mm below the level of the foramen magnum, the patient is considered to have a Chiari I malformation. The Chiari I malformation is best visualized on a sagittal T1-weighted image of the cervical spine.

Discussion
Advances in radiology and neurosurgery have lead to improvements in the diagnosis and treatment of various congenital malformations of the nervous and skeletal system.
Magnetic resonance imaging is the best imaging procedure to evaluate the brain, posterior fossa and spinal cord for congenital abnormalities, especially as it is non-invasive and can obtain images in multiple planes.
Surgical treatment mainstays for Chiari malformation are decompression or shunting and possible laminectomy.

Learning Point
Historically, Hans van Chiari described 4 types of hindbrain anomalies in 1891 and 1895. Arnold described a different classification system.
The Chiari II malformation is synonymous with the Arnold-Chiari malformation. Hans van Chiari also described Budd-Chairi syndrome which is an unrelated liver problem with cirrhosis and ascites due to an obstruction of the hepatic vein by a blood clot or tumor.

Chiari I – caudal displacement of cerebellar tonsils with elongation of the 4th ventricle.
It is associated with syringomyelia in up to 80% of patients. Syringomyelia is a cyst-like formation within the spinal cord that contains altered glial elements.
This may be asymptomatic or have symptoms occurring from infancy to adulthood. Most patients present in the 3rd decade. Hydrocephalus may be present.

Symptoms include:

    Associated with brain and cranial nerves:

  • Ataxia
  • Dysphagia
  • Headache
  • Neck Pain
  • Nystagmus
  • Sleep apnea
  • Torticollis
  • Vertigo
  • Vocal cord paralysis
    Associated with spinal cord dysfunction:

  • Dysesthesia
  • Bowel and/or bladder dysfunction
  • Extremity – weakness or spasticity
  • Sensory loss
  • Scoliosis

Chiari II – caudal displacement of the vermis of the cerebellum, medulla and pons with elongation of the 4th ventricle.
This is almost always associated with a lumbar meningomyelocoele. Hydrocephalus occurs because of aqueductal stenosis.
Patients are usually diagnosed at birth. Chiari II is the most common Chiari malformation.
Clinical symptoms are the same as Chiari I plus those associated with the meningomyelocoele and hydrocephalus.

Chiari III – herniation of the cerebellum into an upper cervical or occipital meningocoele. It may also be associated with a Dandy-Walker malformation.
Because of the extent of the malformation, patients present at birth and have more obvious and extensive symptoms.

Chiari IV – severe hypoplasia of the cerebellum. Because of the extent of the malformation, patients present at birth and have more obvious and extensive symptoms.

Questions for Further Discussion
1. What other congenital abnormalities may be associated with Chiari malformations?
2. What are indications for referral to a neurologist or neurosurgeon?

Related Cases

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

Information prescriptions for patients can be found at MedlinePlus for this topic: Neural Tube Defects.

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

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2180-2186..

Incesu L, Khosla, A. Chiari II Malformation. eMedicine.
Available from the Internet at http://www.emedicine.com/radio/topic150.htm (rev. 11/15/2002 cited 2/12/07).

Siddiqui NH, Laine FJ. Chiari I Malformation. eMedicine.
Available from the Internet at http://www.emedicine.com/radio/topic149.htm (rev.8/11/2005, cited 2/12/07).

Chiari Malformation Type I. Online Mendelian Inheritance of Man.
Available from the Internet at http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=118420 (rev.8/8/2006, cited 2/12/07).

ACGME Competencies Highlighted by Case

  • Patient Care
    4. Patient management plans are developed and carried out.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

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

  • Practice Based Learning and Improvement

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

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

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

    Date
    April 2, 2007

  • Fluoride Varnish – What Is It?

    Patient Presentation
    A 3-year-old male came to clinic for his health supervision visit.
    He had seen a dentist once in his life after a fall and had minor dental trauma. He and his parents brushed his teeth daily with toothpaste. There were no concerns about his oral health.
    He lived in a community with a fluoridated water supply which the family used for cooking and drinking. Dietary history revealed that he drank water, milk, and 1-2 times per week some apple or orange juice. He ate a variety of foods but fewer vegetable choices than his parents wished.
    The past medical history was non-contributory. His immunizations were current.
    The pertinent physical exam showed a male preschooler with growth parameters in the 10-50% for age. His oral examination showed no obvious caries or soft tissue problems.
    The rest of his examination was normal.
    The diagnosis of healthy male was made. He received fluoride varnish on his teeth at the visit and a referral to the local agency which provides reduced-fee dental care was arranged to establish a dental home.

    Discussion
    Dental caries are the most common chronic disease world-wide. Caries are caused by Streptococcus mutans particularly serotypes cricetus, rattus, ferus, and sobrinus.
    By themselves, dental caries cause pain, temperature sensitivity, and swelling. Extension can cause abscesses and deep infections with potentially life-threatening effects, especially if the airway is compromised.

    Fortunately, dental hygiene and fluoride help to prevent caries.

    Epidemiological data has shown that fluoridated water supplies reduce dental caries by 55-60% without significant dental fluorosis.
    Oral health costs for children can be reduced by 50% with the use of fluoride.
    The American Academy of Pediatric Dentistry recommends fluoridating community water supplies.
    In areas where fluoridated water supplies are not available, daily oral fluoride supplements are recommended after carefully reviewing all potential sources of fluoride including toothpaste, fluoride containing dental gels and rinses, beverages (e.g. grape juice), prepared food, and all water supplies for drinking. This review is necessary to help prevent fluorosis especially in small children who may ingest larger amounts of toothpaste and/or other fluoride containing dental products.

    The table below is the recommended oral fluoride supplementation. Dosages are in total milligrams of fluoride ion. Note: the dosage is NOT based upon body weight.

    			Fluoride concentration in parts per million
    Age			<0.3		0.3-0.6		>0.6
    Birth-6 months		0		0		0
    6 months-3 years	0.25 mg 	0		0
    3-6 years		0.5 mg		0.25 mg		0
    6-16 years		1 mg		0.5 mg		0
    

    The first commercially available fluoride-containing toothpaste was Crest® in 1955.

    Learning Point
    Fluoride varnishes have an anticarious effect that has been confirmed in clinical trials with a decrease in caries from 18-70% depending on the study.
    A meta-analysis of 9 studies found that there was a 46% reduction of caries for permanent teeth and a 3% reduction for primary teeth.
    The varnish works to prevent or reverse demineralization of the enamel. There are two formulations available in the U.S.. Financial analysis has found that applications of dental varnish are cost effective in Medicaid-enrolled children.

    To prevent caries, the recommendations currently are to apply fluoride varnish at 6-month intervals to permanent teeth of children who live in communities with all levels of fluoride in their water supplies.
    Studies for primary dentitia are inconclusive,”???but there is no reason currently to assume that it would not provide a similar level of caries protection in younger children.”

    The University of Iowa College of Dentistry gives the following indications for application:

    • Ages 0-36 months, well-child visit, and no application within the past 6 months
    • Cavities, previous cavities, plaque, stained grooves, Medicaid or no insurance, or new teeth erupting
    • Teeth present in the mouth
    • No contraindications to application of varnish

    Application can be performed by a by a dentist or other trained healthcare provider including medical personnel by doing the following:

    • Place the child on the examination table
    • Gently use gloved fingers to open the child’s mouth
    • Remove excess saliva from teeth with gauze
    • Apply a thin layer of varnish to all surfaces of teeth

    The patient should eat only soft foods for rest of day. The patient can brush and floss teeth the following morning (not that evening.
    It is normal for the teeth to appear dull and yellow until they are brushed because of the varnish.

    Questions for Further Discussion
    1. What are the indications for subacute bacterial endocarditis prophylaxis for dental procedures?
    2. What is the fluoride concentration of our local water supply?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for this topic: Tooth Disorders and Child Dental Health
    and at Pediatric Common Questions, Quick Answers for this topic: Dental Care

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

    Newbrun E. Topical fluorides in caries prevention and management: a North American perspective. J Dent Educ. 2001 Oct;65(10):1078-83.

    Peng L, Kazzi AA. Dental Infections. eMedicine.
    Available from the Internet at http://www.emedicine.com/emerg/topic128.htm (rev. 12/4/2004, cited 2/7/2007).

    University of Iowa College of Dentistry. Fluoride Varnish Application. Provider handout (rev. 5/2006).

    American Academy of Pediatric Dentistry. Oral Health Policies. Policy on Use of Fluoride. Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/P_FluorideUse.pdf (rev. 2003, cited 2/7/2007).

    Quinonez RB,
    Stearns SC,
    Talekar BS,
    Rozier RG,
    Downs SM. Simulating Cost-effectiveness of Fluoride Varnish During Well-Child Visits for Medicaid-Enrolled Children. Arch Pediatr Adolesc Med. 2006;160:164-170.

    Adair SM.
    Evidence-based use of fluoride in contemporary pediatric dental practice.
    Pediatr Dent. 2006 Mar-Apr;28(2):133-42.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

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

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • 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.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    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
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    March 26, 2007

  • How Common is Syncope?

    Patient Presentation
    A 10-year-old female was referred to cardiology clinic after an episode of syncope 1 week previously. After she had been running sprints at the end of a sports practice, she went to the bathroom. After voiding, she stood up, felt lightheaded, warm, shaky, her heart was beating faster than it had been, she had blackness in her vision and then collapsed.
    She had no bladder or bowel incontinence. She does not know how long she was unconscious for, but a friend helped her get up.
    She reports dizziness at other times when she gets up quickly. One episode occurred about a month ago. She did not lose consciousness and says she continued her activities.
    She says she does drink water and sports drinks, and only urinates one time during the school day. She reports no caffeine or additional salt intake in her diet.
    She says she has no chest pain, palpitations, exercise intolerance or shortness of breath.
    The past medical history and review of systems are otherwise negative.
    The family history is negative for syncope, heart abnormalities, seizures and sudden death.
    The pertinent physical exam shows a healthy appearing school age female. Pulse is 72, respirations are 20, and blood pressure in the right arm is 102/61 with no significant differences in other extremities.
    Height and weight are in the 50-75% for age. Neck had no lymphadenopathy or thyromegaly. Lungs were clear. Heart showed a regular rate and rhythm without murmurs. Normal S1 without murmurs and normal splitting of S2.
    Pulses were equal in upper and lower extremities. Neurological examination was also normal.
    The work-up included an electrocardiogram which showed mild sinus bradycardia with a heart rate of 55 but was otherwise normal including a correct QT interval with no pre-excitation.
    The diagnosis of reflex syncope was made. She was advised to increase her fluid intake, add a moderate amount of salt to her food and to limit caffeine intake. If the symptoms return she will then call for followup.

    Discussion
    Transient loss of consciousness (TLOC) is a common presenting problem in children. Physical collapse may or may not be associated with TLOC as a presenting problem.
    The differential diagnosis of TLOC and collapse is often compounded by imprecise terminology use.

    The following algorithm can be considered when trying to differentiate between the multiple causes of collapse and TLOC.

    1. Did the patient collapse? (defined as abrupt loss of postural tone with or without TLOC)

    • No – consider other causes
    • Yes – ask question 2 below

    2. Did the patient have a spontaneous TLOC?

    • No – consider the causes below:
      • Falls
      • Hypoglycemia or other metabolic abnormalities
      • Medication side effects or drug abuse
      • Transient ischemic attack or cerebrovascular accident
    • Yes – consider the causes below:
      • Syncope (defined as TLOC caused by global impairment of cerebral perfusion which then causes the collapse. Onset is relatively rapid, recover is spontaneous, complete and usually prompt. )
      • Epilepsy (defined as spontaneous inappropriate discharge of cortical neurons leading to a clinical event)
      • Psychogenic seizure (defined as a transient neurological disturbance without organic cause)

    Epilepsy is also a common of TLOC. Unfortunately, there is a high rate of misdiagnosing epilepsy as the cause when other causes are the real culprits. In children, the misdiagnosis rate is as high as 40%.
    Epilepsy is a clinical diagnosis, but neurological consultation is necessary to confirm the diagnosis. Electroencephalogram also may be helpful in confirming the diagnosis.

    Psychogenic seizures are often seen in children and adults under age 50. The episodes are frequent, often occurring many times per day, but testing shows that the TLOC occurs without any change to blood pressure, heart rhythm or electroencephalic tracings.
    Tilt table testing may be help to make these determinations and reassuring the patient and family that there is no underlying cardiac or neurological events. Tilt table testing is being used less frequently though because of lack of sensitivity and specificity. Treatment with psychiatric help can then be offered.

    Learning Point

    Syncope is common with ~15% of children under the age of 18 having the problem. More females than males have syncope.

    Reflex syncope, also known by many other names including vasovagal syncope, neurocardiogenic syncope, pallid breath holding spells and others, is probably the most common cause of syncope.
    The initial event causing the reflex syncope is not known but higher cerebral centers appear to be involved. Some speculate that reflex syncope may be an evolutionary adaption, whereby in response to a predator, a person will abruptly collapse and become pallid. The person would appear to be dead to the predator and thereby escape being prey.
    Reflex syncope usually has a history of associated symptoms such as nausea, vomiting, feeling hot, sweating, lightheadedness, “closing in of vision” and palpitations. The patient also turns pale and consciousness quickly returns. There is often a precipitating event such as standing for a long period of time in a hot environment, a frightening episode such as the sight of blood, or intense pain or trauma.
    Recommended treatments include avoid caffeine (to avoid its diuretic effects), increasing fluid intake, and adding some salt (to increase fluid retention). Some cardiologists recommend sports drinks if patients are very active.
    Also having the patient be aware of common precipitating events so they can be avoided or modified, e.g. arising slowly after sitting for a long time. Patients often have resolution of the episodes within 6-9 months.

    Syncope after exercise is often caused by reflex syncope.
    Syncope during exercise may be caused by an underlying cardiomyopathy or arrhythmia and should be investigated. Any family history of underlying cardiac disease should also prompt investigation. Other indications for referral to a cardiologist include episodes that includes chest pain, palpitations, an abnormal electrocardiogram, syncope that causes injury or recurrent syncope.
    Some physicians recommend that any patient who has a syncopal episode have an electrocardiogram at least once. A search of clinical practice guidelines of the American Academy of Pediatrics, American Academy of Neurology and the American Heart Association did not find any specific recommendations for syncope and its evaluation.

    Questions for Further Discussion
    1. What are indications for an electroencephalogram?
    2. What are the indications for Holter monitoring?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Fainting, Arrhythmia and Epilepsy
    and at Pediatric Common Questions, Quick Answers for this topic: Fainting and Epileptic Seizures.

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

    Fitzpatrick AP, Cooper P. Diagnosis and management of patients with blackouts.
    Heart. 2006 Apr;92(4):559-6.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1892-1894.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

    7. All medical and invasive procedures considered essential for the area of practice are competency 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.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    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
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Nicholas Von Bergan, M.D.
    Pediatric Cardiology Fellow, Children’s Hospital of Iowa

    Date
    March 5, 2007

  • How Do You Differentiate Fears and Phobias?

    Patient Presentation
    A 7-year-old female came to clinic with her mother for her health maintenance visit. They had no concerns but her mother wanted to know what she could do to comfort her daughter during thunderstorms.
    The previous spring, there had been a series of thunderstorms that had made the girl very upset. Since then, the girl has become very afraid during thunderstorms and is very anxious even during rainstorms.
    Her mother states that if she even hears that there may be a thunderstorm she begins to become upset. She also does not like to read books where thunderstorms or rainstorms occur.
    During the storms, she is comforted by her mother, siblings or other adults. She continues with her activities but does remains vigilant.
    If it is actively lightening and thundering though she sometimes wants to cover up under a blanket or pillow.
    If the storms occur at night, she comes to her mother’s bed for comfort, and falls back to sleep without much difficulty.
    If it is just raining, but the storms continue for a long period of time, she is less anxious overall and becomes less so with time.
    She is not scared of other weather conditions and has no other exaggerated fears.
    The symptoms are not increasing and possibly may be slightly better according to her mother.
    The social history shows a second grader doing well in school, with many friends, who likes swimming and drawing.
    The family history is negative for any psychiatric illness
    The pertinent physical exam shows a normal healthy female, who simply states, “I don’t like storms!”After consulting an electronic version of the Diagnostic and Statistical Manual of Mental Disorders to review the criteria for a phobia, the diagnosis of an exaggerated fear is made. Since the symptoms are limited only to various storms, are not increasing in quantity or quality, and the current emotional support seems to help the child,
    the mother was reassured to just continue to comfort the girl during storms. However, the mother was told to call if the symptoms seem to be worsening and potentially short term counseling would be beneficial.

    Discussion
    Fears are protective. They help to keep people safe from a variety of potentially harmful factors in the environment.
    “Fear is an unpleasant emotion with cognitive, behavioral, and psychological components. It occurs in response to a consciously recognized source of danger, either real or imaginary.””Phobia [or a specific phobia] is a persistent and compulsive dread of and preoccupation with the feared object or event.” Phobias interfere with a child’s functioning.

    The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for a specific phobia includes:

    • The patient has persistent or irrational fear that is unreasonable or excessive and is triggered by the presence or anticipation of a specific object or situation.
    • Exposure to the above noted event or object almost always results in an immediate anxiety response.
    • The person acknowledges this response to be unreasonable or excessive.
    • The person either avoids such situations or objects or else experiences exposure with intensive anxiety or distress.
    • The avoidance or distressful response significantly interferes with a person’s daily functioning.
    • Duration is at least 6 months for individuals younger than 18 years.
    • The anxiety, distressful response, or avoidance is not accounted for by other mental disorders .
    • The patient must have 1 of the following 5 subtypes that best describe phobias: animal, natural environment, blood-injection injury, situation or other (which must be distinguished from normal fear and anxiety).

    Often there is a triggering event for a fear or phobia, e.g. thunderstorm. The fear can build because the child is not developmentally old enough to allay the fear or be able to be emotionally comforted with a reasonable explanation.
    Cognitively and emotionally the child may not be able to understand that the current situation is safe or that the situation is not likely to be repeated. For example, a large dog knocks over a 3 year old boy and he has a few scratches.
    The child may not be old enough to understand that he is now safe with an adult and the dog is unlikely to come back and hurt him again.
    Instead the next time the boy encounters a dog, he seeks an adult, climbs play equipment or runs behind an object. These actions would be protective. But if he would cry uncontrollably after the dog was gone, and after a reasonable time of being comforted, then he may be having an exaggerated fear or even a phobia.

    Fears are normal and occur in all children. Phobias occur in 7-9% of children. Different fears occur at different ages:

    • Infant and Toddler – separation, noises, falling, animals, toilet training, bath, bedtime
    • Preschoolers – animals, bedtime, monsters/ghosts, getting lost
    • School age (5-9 years) – separation, noises, falling, animals, bedtime, monsters/ghosts, divorce, getting lost, loss of parent
    • School age (9-12 years) – falling, social rejection, war, new situation, adoption, burglars
    • Teenagers – adoption, burglars, injections, sexual relations

    Treatment is generally supportive. Parents need to understand that the fear is real to the child and that the child wants to withdraw from the feared object or situation.
    Over time with support, the child will gain increased skill at handling the feared object or situation.
    Counseling is recommended when a fear becomes more generalized, is impeding activities or if the fears are a realistic response to a threatening environment.
    Medication is sometime recommended for phobias.

    Learning Point
    Diagnostic and Statistical Manual of Mental Disorders should be consulted when symptoms may be more than a simple fear. In general, fears and phobias can be differentiated based upon the following:

    				Fear	Phobia
    Reasonable triggering
      event as likely cause		Yes	No
    Responds to reassurance		Yes	No
    Is distractible			Yes	No
    Interferes with activities	No	Yes
    

    Questions for Further Discussion
    1. What other disease/problems should be considered in the differential diagnosis of a fear or phobia?
    2. What are the other anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders?

    Related Cases

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

    Information prescriptions for patients can be found at MedlinePlus for these topics: Anxiety and Phobias

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

    Augustyn M. Fears. In Behavioral and Developmental Pediatrics. Parker S, Zuckerman B. Little, Brown and Company. Boston, MA. 1995;140-142.

    Friedman SL, Munir KM.
    Anxiety Disorder: Specific Phobia. eMedicine.
    Available from the Internet at http://www.emedicine.com/ped/topic2659.htm (rev.8/7/2006, cited 1/31/2007).

    American Psychiatric Association. Specific Phobia. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Available from the Internet at: http://www.behavenet.com/capsules/disorders/specphob.htm(rev. 2000, cited 1/31/2007)

    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
    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.

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

    Date
    February 26, 2007