Month: April 2012

What Are the Different Types of Conjoined Twins?

Patient Presentation
While volunteer teaching in the human body curriculum of a local elementary school, the students asked a pediatrician several questions about twins. They were especially interested in conjoined twins since there had been some recent media stories about a set of conjoined twins. He explained that people weren’t sure exactly how conjoined twins happened, but the usual thought was that it was due to cells not splitting apart completely. The students also wanted to know why conjoined twins were sometimes called Siamese twins. He said he didn’t know this answer, but later looked up the answer using the Internet and sent the answer to the children.

Discussion
Conjoined twins (CT) have sparked people’s interest for thousands of years. The Roman god Janus with two heads and faces is one example. The Greek mythological creature the centaur is another example being part human and part horse. The Babylonian god Marduk was a “double-god” with 4 ears and 4 eyes to be able to see and hear everything.

In Kent, England in ~1100 A.D., the Biddenden maids, Mary and Eliza Chulkhurst, supposedly were CT joined at the hip and shoulder and lived for 34 years. After their death they gave land to the local church and biscuits/cakes with their likeness has been given to the poor at Easter in their honor since. One of the most famous sets of conjoined twins were Chang and Eng Bunker. Born in Siam (modern day Thailand) they were thought to give rise to the common term “Siamese twins” for CT. They were joined at the lower chest and livers, lived for 64 years, married sisters and had 21 children between them. They traveled throughout the world as entertainers including working with the famous P.T. Barnum.

The developmental cause of the malformation CT is uncertain with different data supporting a problem with fission (or incomplete clevage along the plane in a single embryo) or fusion (of two separate embryos). The prevalence is estimated to be 1;50,000 pregnancies but 1;200,000 live births. There is great variation, but it appears that CT are more common in females and in some places in the world including South America. Survival is low and many die in the early natal period or as part of surgical separation. As with all people, each set of CTs and each person within the set is unique. The exact location, organs involved, circulation status to the organs and many other factors help to determine survivability as well as the possibility of attempting surgical separation. A multidisciplinary team approach to surgical separation is necessary including extensive pre-surgical radiologic imaging and planning as well as ethical considerations.

Learning Point
The types of conjoined twinning are usually noted by the union site with the suffix “pagus” attached. Pagus means fixed or solid.
The table below lists the CT types, union site, primary shared structures and the incidence from the International Clearinghouse for Birth Defect Surveillance and Search in 2011.
See also line drawings of different types of CT.

  • Thoracopagus
    • Location: Chest and thorax to umbilicus
    • Sternum, diaphragm upper abdominal wall, has heart and liver abnormalities
    • Incidence: 42%
  • Parapagus
    • Location: Ventrolateral fusion of lower abdomen and pelvis, has genitourinary anomalies
    • Incidence:14.5%
  • Omphalopagus
    • Location: May be same as thoracopagus but has two separate hearts
    • Incidence:5.5%
  • Cephalopagus
    • Location: Head but not face or foramen magnum, brains are usually separate
    • Skull, meninges and venous sinuses involved
    • Incidence:5.5%
  • Craniopagus
    • Location: Head at any location
    • Incidence:3.4%
  • Ischiopagus
    • Location: Hip from umbilicus to conjoined pelvis
    • Genitourinary and gastrointestinal tracts often involved
    • May have different number of legs (i.e. 2, 3 or 4)
    • Incidence:1.8%
  • Rachipagus
    • Location: Spine with vertebral and neural tube defects
    • Incidence:1.0%
  • Pyopagus
    • Location: Buttocks with sacrum and coccyx anomalies
    • Incidence:1.0%
  • Parasitic
    • Location: Incomplete twin attached to other twin at any location
    • Incidence:3.0%
  • Type Not Specified
    • Incidence:21.4%

    Questions for Further Discussion
    1. What would be the role of a general pediatrician on the multidisciplinary team caring for CTs?
    2. What ethical issues arise when considering surgical separation of CT?
    3. How common are monozygotic or dizygotic twins?
    4. What medical complications can occur because of multiple births?

    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: Twins, Triplets and Multiple Births and Birth Defects.

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

    To view images related to this topic check Google Images.

    Wikipedia. Biddenden Maids. Available from the Internet at http://en.wikipedia.org/wiki/Biddenden_Maids (rev. 1/13/2012, cited 2/29/2012).

    Find A Grave. Chang and Eng Bunker. Available from the Internet at http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=1250 (rev. 1/1/2001, cited 2/29/2012).

    McHugh K, Kiely EM, Spitz L. Imaging of Conjoined Twins. Pediatr Radiol. 2006;36:899-910.

    Mutchinick OM, Luna-Muñoz L, Amar E, et.al.. Conjoined twins: a worldwide collaborative epidemiological study of the International Clearinghouse for Birth Defects Surveillance and Research. Am J Med Genet C Semin Med Genet. 2011 Nov 15;157C(4):274-87.

    Lee M, Gosain AK, Becker D. The bioethics of separating conjoined twins in plastic surgery. Plast Reconstr Surg. 2011 Oct;128(4):328e-334e.

    ACGME Competencies Highlighted by Case

  • 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.
    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
    Professor of Pediatrics, University of Iowa Children’s Hospital

    • What Causes Vaginal Discharge?

    Patient Presentation
    A 1-month-old female came to clinic with a 2 day history of increased vaginal discharge. The mother noted that there was an increase in the amount but that the discharge continued to be clear-colored and have a thin consistency. The infant had had increased amounts of stools 4 days ago and the mother noted a red rash on the perineum that she had been using a barrier cream on. The infant was otherwise asymptomatic, and the mother had no concerns about potential sexual or physical abuse. The past medical history revealed a full-term infant female.

    The pertinent physical exam showed a well-appearing female growing on the 10-50% growth curves and with normal vital signs. Her perineal area showed moderate generalized erythema of the convex and concave areas of the perineum, labia and buttocks. There were satellite lesions on lower abdomen and inner thighs. Normal appearing vaginal secretions were seen. Her anatomical structures were normal in appearance. The diagnosis of candidal diaper dermatitis causing vulvovaginitis was made and anti-fungal cream was recommended. The mother was educated about normal changes in vaginal secretions in young children.

    Discussion
    Vulvovaginitis can occur at any age but is a very common problem in prepubscent females. In this age group it is often caused by irritants and non-specific inflammation. In adolescents and adult females, sexually transmitted infections become another common problem. Sexual abuse can occur at any age.

    Normal vaginal secretions are usually thin, and clear to white with a variable amount. Vaginal discharge that is a different consistency, malodorous, accompanied by blood, pain, pruritis, or dysuria is usually not physiologic. Abdominal pain, emesis and fever may indicate pelvic inflammatory disease.

    • If bloody, consider foreign body, Shigella, Streptococcus, abuse, estrogen withdrawal, and menses.
    • If white, cottage-cheese like, consider Candida.
    • If white-yellow, consider normal variation, irritation and Chlamydia.
    • If yellow-green, and thick, consider foreign body, Neisseria gonorrhea and trichomonas.

    Non-specific vaginal discharge is usually treated by removing the irritant, sitz baths and education about proper hygiene and increasing air flow to the area. Treatment should also be given for specific causes

    Learning Point
    The differential diagnosis of vulvovaginitis includes:

    • Normal variation
      • Newborn – thin discharge, may have blood with estogen withdrawal
      • After newborn through puberty – thin mucoid discharge
      • After puberty – leukorrhea – thin, clear to yellow, not malodorous
      • Pregnancy – may increase the amount
    • Irritants – one of the most common causes
      • Poor hygiene
      • Bubble bath and soaps
      • Douches, spermicides, and latex
      • Masturbation
      • Restrictive clothing
    • Infectious – may be due to actual infection and/or abnormal balance of vaginal flora
      • Bacterial
        • Chlamydia
        • Escherichia coli
        • Gardnerella
        • Gonorrhea
        • Herpes
        • Staphylococcal
        • Streptococcal
        • Shigella
        • Trichomonas
        • Ureaplasma urealyticum
      • Fungal
        • Candida
        • Tinea cruris
      • Parasite
        • Pinworm
        • Pediculosis pubis
        • Scabies
    • Dermatologic
      • Eczema
      • Lichen sclerosis et atrophicus
    • Foreign body
      • Retained tampon
      • Sand
      • Toilet paper
      • Multiple other objects
    • Systemic illness
      • Crohn’s disease
      • Diabetes
      • Scarlet fever
    • Other
      • Tumor
      • Sexual abuse
      • Congenital abnormality
      • Urethral prolapse

    Questions for Further Discussion
    1. How can sexual abuse present? See also What Are Some of the Presentations for Child Abuse and Neglect? http://www.pediatriceducation.org/2005/06/06/
    2. What are the legal requirements for treating minors with sexually transmitted diseases?
    3. What local resources are avaiable for gynecological consultation in your location?

    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: Vaginal Diseases, Vulvar Disorders and Infant and Newborn Care.

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

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:338-339.

    Sifuentes M. Vaginitis. In Pediatrics a Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;279-282.

    Garden AS. Vulvovaginitis and other common childhood gynaecological conditions. Arch Dis Child Educ Pract Ed. 2011 Apr;96(2):73-8.

    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.

    Author

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

    • Is Television All Bad?

    Patient Presentation
    An 18-month-old male came to clinic with a fever for 2 days to 101° F. He had a runny nose, mild cough and had been pulling his left ear and complaining of pain. He attended an in-home child care placement where two other children had similar symptoms. The pertinent physical exam showed a mildly ill child with normal vital signs and growth problems. HEENT examination demonstrated copious clear rhinorrhea, normal pharynx and a left tympanic membrane that was red, bulging, with no light reflex and no mobility with insufflation. His right ear was grey with a splayed light reflex and normal insufflation.

    The diagnosis of acute otitis media was made and antibiotics were prescribed. During the visit, the child had been offered his mother’s smartphone to play games with. She commented that “he always needs to play with my phone” and that “I often can’t even make a call because he’s playing with it.” The physician took this opportunity to try to educate the mother about electronic media use, but she remained skeptical. The child began tantruming as they were leaving the office, because the mother took the phone from him to answer a call.

    Discussion
    “This instrument can teach, it can illuminate; yes, and it can even inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise it is merely wires and lights in a box.”

    – Edward R. Murrow, Television Pioneer, 1958 Television and electronic media viewing are almost ubiquitous in the current United States culture. About 90% of parents say their < 2 year old children watch some form of electronic media with an average of 1-2 hours/day of television and 14% of 6-23 months old watch 2 or more hours/day. Children under age 6 years watch about 2 hours of electronic media a day and children 8-18 years watch about 6 hours/day. Parents are often not aware of the amount of time a child may be exposed to electronic media. A 2009 study of in-home and center based child care found that in-home child care had more electronic media viewing (~3 hours/day) than center-based care (~1 hour/day) for preschool children. While televisions and in-car DVD players are specific for particular places, parents often are not aware of the other electronic media exposure dismissing the amount of time children may spend with Apple® iPads and smartphones. These can be significant particularly with the use of wireless Internet connectivity.

    Negative effects shown in studies of television and electronic media have included poor attention, language development, social skills, memory, reading comprehension, obesity, sleep problems and aggression/violence.

    In the late fall of 2011, the American Academy of Pediatrics (AAP) reasserted its recommendations discouraging media use for all children under 2 years of age. The AAP also recommended that children play with their parents in unstructured, unplugged environments and that families should read with their children to “foster their child’s cognitive and language development.” If parents do use electronic media, the AAP recommends parents review the content before the child sees it, watching the media with the child and being aware of what adult content is often inadvertently being viewed by having media on in a room where a child is playing. Additionally, the AAP recommends no televisions in a child’s bedroom. The AAP also recommends limiting 1-2 hours/day of quality electronic media for older children.

    Parental perceptions of media restriction shows at least 3 main problems. First is limiting electronic media will cause family conflict. Second, electronic media offers free babysitting, entertainment and potentially educational opportunities. And third, replacement of electronic media takes time “…away from parents and requires monetary and community resources that are not available.”

    Learning Point
    There is data that supports that educational media has beneficial effects or at least is similar to non-media activities in not having negative effects. Most of this data is for older children though.

    A 2011 study of 4 year olds found that a fast-paced television cartoon had detrimental effects on short term executive functioning, when compared to educational television and drawing activities. Educational television and electronic media is positively linked with academic achievement and in cognitive skills such as visual spatial skills and problem-solving skills. Other data supports improved school readiness, language and social skills. But how knowledge from electronic media is transferred to other venues is not fully understood. Data like the study above also does not show an advantage of electronic media over other instructional forms.

    Development probably plays a large role in how the electronic media consumption influences a particular child. One study found that “…the association between early television viewing and subsequent attentional problems is specific to noneducational viewing and to viewing before age 3.” Media use in older children and teens has also been found to be beneficial. A study found that the television show “Mythbusters” (an educational television program depicting scientists attempting to scientifically prove or disprove a particular myth) accurately depicts science and engineering culture and therefore can show students what having a career in science, technology, engineering and mathematics may hold for them.

    As with many things in life, everything in moderation. Just like too much or too little water causes flooding or drought, or too much or too little sun can cause skin cancer or Vitamin D deficiency, electronic media use should be moderated, and monitored by parents to help their children.

    Questions for Further Discussion
    1. What positive or negative effects have you seen in your practice regarding electronic media use?
    2. How receptive are parents to counseling regarding electronic media use in your practice?

    Related Cases

      Disease: Television | Electronic Media | Parenting

    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: Parenting

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

    To view images related to this topic check Google Images.

    Radio Television Digital News Association. Edward R. Murrow Speech. Available from the Internet at http://www.rtdna.org/pages/media_items/edward-r.-murrow-speech998.php (rev.1958, cited 2/21/12).

    Zimmerman FJ, Christakis DA. Associations between content types of early media exposure and subsequent attentional problems. Pediatrics. 2007 Nov;120(5):986-92.

    Schmidt ME, Vandewater EA. Media and attention, cognition and school achievement. Future Child. 2008:18;63-85.

    Christakis DA, Garrison MM. Preschool-aged children’s television viewing in child care settings. Pediatrics. 2009 Dec;124(6):1627-32.

    Stout H. Toddlers Favorite Toy: The iPhone. New York Times. Available from the Internet at http://www.nytimes.com/2010/10/17/fashion/17TODDLERS.html?pagewanted=all (rev. 10/15/10, cited 2/21/12).

    Council on Communications and Media, Brown A. Media use by children younger than 2 years. Pediatrics. 2011 Nov;128(5):1040-5.

    Zavrel EA. How the Discovery Channel Television Show “Mythbusters” Accurately Depicts Science and Engineering Culture. J Sci Ed Tech. 2011:20:201-207.

    Evans CA, Jordan AB, Horner J. Only Two Hours? A Qualitative Study of the Challenges Parents Perceive in Restricting Child Television Time. J Fam Issues. 2011:32:1223-1244.

    Lillard AS, Peterson J. The immediate impact of different types of television on young children’s executive function. Pediatrics. 2011 Oct;128(4):644-9.

    How TV Affects Your Child. KidsHealth. Available from the Internet at http://kidshealth.org/parent/positive/family/tv_affects_child.html (rev. 2012, cited 2/21/12).

    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.
    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.

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

    Author

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

    • How Common Is Human Metapneumovirus?

    Patient Presentation
    Patient Presentation
    A 15-year-old male came to the emergency room with cough, runny nose and fever to 101.5° F for 2 days. The cough was increasing in intensity overall and occurred day and night. There was no paroxysmal quality and the patient said he felt breathless. The past medical history was positive for mild intermittent asthma with the last episode occurring more than 5 years ago. He denied chest pain, myalgia, arthralgia, sore throat, emesis, nausea or diarrhea.

    The pertinent physical exam showed a tired appearing male whose oxygen saturation was 93%, respiratory rate of 40, with a normal pulse, blood pressure and growth parameters. He had very mild intercostal retractions, but no tracheal tugging or nasal flaring. He had no cyanosis or stridor. HEENT showed mild clear rhinorrhea. Lungs revealed very mild intermittent wheezes at the bases. The rest of the examination was normal. The radiologic evaluation demonstrated some mild perihilar streaking without focal abnormalities consistent with viral pneumonia. The diagnosis of viral pneumonia was made. The patient was given an albuterol nebulizer treatment and had some moderate improvement. He was discharged home with followup in 2 days with his regular physician. At followup he reported some moderate improvement with albuterol treatments and his fever had subsided 1 day previously. He was not tachypneic and had no signs of respiratory distress. The laboratory evaluation of a nasal wash specimen done in the emergency room was positive for human metapneumovirus.

    Discussion
    Acute respiratory infections particularly clinical pneumonia are one of the most common causes of death world-wide. Clinical pneumonia in children less than 5 years old in developing countries is approximately 0.29 episodes per child-year or about 151.8 million cases per year of which 8.7% require hospitalization. An additional 4 million children are hospitalized in developed countries per year. There are great differences across the world with the distribution of pneumonia cases. The 5 countries with the highest incidence of clinical pneumonia are India, China, Pakistan, Bangladesh and Nigeria. Even within these countries there are differences, for example rural areas often have higher incidences. Estimates of pneumonia mortality in children less than 5 years of age is about 2 million per year. This is probably an underestimate especially in the neonatal age group. Again there are differences in the distribution of the deaths ranging from 45% in Africa to 2-3% in Europe and the Americas. About 2/3rds of deaths occur in 10 countries: India, Nigeria, Democratic Republic of the Congo, Ethiopia, Pakistan, Afghanistan, China, Bangladesh, Angola and Niger.

    Definite risk factors affecting the incidence of childhood pneumonia include low birth weight, malnutrition, non-exclusive breastfeeding during the first 4 months of life, lack of measles vaccination in first 12 months of life, crowding and indoor air pollution. Other likely risk factors include maternal caregiving experience, parental smoking, concomitant diseases and zinc deficiency.

    Common bacterial organisms causing pneumonia worldwide include Streptococcus pneumonia (leading bacterial cause when isolated), H. influenza type b and non-typeable, Staphlococcus aureus, Klebsiella pneumonia, Mycobacterium tuberculosis, and non-typhoid Salmonella. Other important organisms causing pneumonia including Mycoplasma pneumoniae, Chlamydia species, Pseudomonas, Escherichia coli, and Pneumocystis. Common viral causes of pneumonia include Respiratory Syncytial virus, Influenza and B, Parainfluenza, Human metapneumovirus and Adenovirus. Measles and varicella are two other important causes. RSV is the most common viral cause when isolated in many studies.

    There can be difficulties in detecting respiratory viruses including not actually testing for a particular organism or differences in detection methods. One study in Finland found ~15% (5% for each group) of rapid virus detection specimens had adenovirus, human metapneumovirus and human bocavirus (a Parvoviridae virus causing respiratory infections identified in 2005). Co-infection rates between the viruses ranged from 1% (hMPV and Adenovirus) to 12% (hMPV and Human Bocavirus). hMPV and RSV was 4%. In another study in China found co-infection rate of hMPV and RSV of 25%.

    Learning Point
    Human metapneumovirus (hMPV) is a single-stranded RNA virus in the Paramyxoviridae family that is closely related to avian metapneumovirus. It was identified in 2001 in the Netherlands. It can cause illnesses that range from asymptomatic to severe respiratory distress and possibly death. Young children under age 2 are particularly susceptible. Twenty-five percent of children 6-12 months were seropositive for past infection and this increased to 100% by age 5. hMPV can occur in all ages. It occurs in all areas of the world and is seasonal in nature.

    Questions for Further Discussion
    1. What are indications for hospitalization for pneumonia?
    2. What treatment is available for patient hospitalized with pneumonia?

    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: Pneumonia</a

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

    To view images related to this topic check Google Images.

    Arnold JC, Singh KK, Spector SA, Sawyer MH. Undiagnosed Respiratory Viruses in Children. Pediatrics. 2008;121;e631.

    Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology childhood pneumonia. Bulletin of the World Health Organization. 2008;321-416.

    Domachowske J, and Steele RW. Pediatric Human Metapneumovirus. Medscape. Available from the Internet at http://emedicine.medscape.com/article/972492-overview (rev. 10/24/11, cited 2/19/12).

    Zhao X, Chen X, Zhang Z. Outbreak of Human Metapneumovirus Infection in Children in Chongqing, China. Pediatrics. 2008;s135.

    ACGME Competencies Highlighted by Case

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

  • 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.

    Author

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