UCLA DEPARTMENT OF PEDIATRICS

Pediatric Clerkship

Stephen L. Shih, M.D.	Shahram Yazdani, M.D.
Class of 2005	Clerkship Director

Download revised version August 2005

Microsoft Word File

Table of Contents

Click on the underlined sections for more information.

Introduction

Pediatric Clerkship Goals and Objectives
General Goals
Learning Objectives
I. Health Supervision
II. Growth
III. Development
IV. Behavior
V. Nutrition
VI. Issues Unique to Adolescence
VII. Issues Unique to the Newborn
VIII. Common Pediatric Illnesses
IX. Therapeutics
X. Fluids and Electrolytes
XI. Pediatric Emergencies (I)
XII. Pediatric Emergencies (II)
XIII. Child Abuse

Lecture Content
Health Supervision and Anticipatory Guidance
Endocrine
Child Development
Feeding and Nutrition
Adolescent Medicine
Nursery
Allergy/Immunology
Cardiology
Dermatology
Gastroenterology
Hematology/Oncology
Infectious Diseases (including Immunizations)
Nephrology
Neurology
Fluids and Electrolytes
Pediatric Emergencies I Toxicology
Pediatric Emergencies II Critical Care
Child Abuse

Clerkship Director Sessions

Clinic Learning Objectives

Ward & Nursery Learning Objectives

Clinic Responsibilities

Ward Responsibilities

Evaluation/Attendance Policies

Supplemental Readings
Linder B. Short stature: etiology, diagnosis, and treatment. JAMA 260(1988):3171-75.
Krane EJ. Diabetic ketoacidosis: biochemistry, physiology, treatment, and prevention. Pediatric Clinics of North America 34(1987):935-57.
Bithoney WG, Dubowitz H, and Egan H. Failure to thrive/growth deficiency. Pediatrics in Review 13(1992):453-60.
Oski FA. Iron deficiency - facts and fallacies. Pediatric Clinics of North America 32(1985):493-97.
Anderson MM. Principles of care for the ill adolescent. Adolescent Medicine: State of the Art Reviews 2(1992):441-58.
Jones KL. Fetal alcohol syndrome. Pediatrics in Review 8(1986):122-26.
Chasnoff IJ. Newborn infants with drug withdrawal symptoms. Pediatrics in Review 9(1988):273-77.
Howle VM. Otitis media. Pediatrics in Review 14(1993):320-23.
Segel GB. Anemia. Pediatrics in Review 10(1988):77-88.
Manno CS. Difficult pediatric diagnoses: bruising and bleeding. Pediatric Clinics of North America 38(1991):637-55.
Freeman JM and Vining EPG. Decision making and the child with febrile seizures. Pediatrics in Review 13(1992):298-304.
Prensky AL. Differentiating and treating pediatric headaches. Contemporary Pediatrics 1(1984):12-45.
Yadin, O. Hematuria in Children. Pediatric Annals 23(1994):474-94.
Ettenger, R. The Evaluation of the Child With Proteinuria. Pediatric Annals 23(1994):486-94.

Introduction

Welcome to Pediatrics

Starting on May 20, 1996, UCLA-CHS is implementing a new, revised pediatric clerkship. The entire curriculum has been reworked to teach medical students general pediatric knowledge and skills that every physician should know. The revision is based on learning objectives from the 1994 Ambulatory Pediatrics Association Core Curriculum in Pediatrics.

This syllabus will serve as a guide for the student throughout the clerkship. The Learning Objectives section outlines topics in 13 main categories that students should master, from either lectures, readings, or clinical experiences. In each category, the suggested readings and study guide questions are listed. The readings are an introduction to the topic and are largely from the required text or review articles. The study guide questions help the student gauge how well the category has been mastered. These questions are also representative of the types of questions that will be asked on the Pediatric Clerkship Exam. The Pediatric Clerkship Exam was chosen as the final exam because it is a better measure of the general pediatric knowledge that every student should have mastered after finishing the clerkship.

I would like to you to select one of two textbooks for reference and study during the clerkship: Pediatrics: A Primary Care Approach by Berkowitz or Pediatrics by Bernstein and Shelov. Berkowitz is stronger in the areas of behavior and development, while Bernstein and Shelov go into greater detail about common pediatric illnesses. Both should be available in the medical school bookstore, and you may want to look at them to see which style best matches your own needs. Supplementary readings in the syllabus go into greater depth on selected pediatric topics. Self-education is an important element of the clerkship, and we have structured the schedule to give you time to read. Try and make the most of this opportunity by taking an active role in your own education.

The revised pediatric clerkship at CHS reflects a year of planning, which included improving the core lecture series, developing a syllabus, and faculty development (including housestaff orientation to medical student teaching). Alice Kuo, Class of 1996, was instrumental in planning the new curriculum and preparing this syllabus. We hope that this new curriculum will be an exciting and enjoyable educational experience for all of you. We invite any feedback during or after your experience on the clerkship.

Stuart J. Slavin, M.D.
Clerkship Director

Pediatric Clerkship Goals and Objectives

General Clerkship Goals

To acquire a fund of knowledge about pediatrics necessary for any physician regardless of his or her future area of interest.

To gather, organize, and record health and illness data on pediatric patients in various age groups: newborn, infant, toddler, pre-school, school-age, and adolescent. This includes:
a. The ability to take a thorough history
b. The ability to carry out a thorough physical examination and developmental assessment
c. The ability to record the above in conventional or problem-oriented format
d. The ability to synthesize and analyze the information and to develop an approach to differential diagnoses
e. The ability to formulate a plan of evaluation with critical use of the laboratory and other diagnostic studies with justification (medical and financial)
f. The development of skills in concise case presentation
g. The acquisition of knowledge about general approaches to patient management (rather than fine detail)
h. The development of skills in performance of simple procedures.

To review the pathophysiology and background information about disease entities encountered and the effects of disease on the developing child.

Learning Objectives

I. Health Supervision	Site where taught
Learning Objectives
1. Describe the content of a health supervision visit and the factors used to determine the frequency of such visits.	Orientation
2. Gather health supervision data from a focused history and physical examination.	Clinic
3. Discuss the appropriate use and interpretation of the following screening tests:	Orientation
A. Neonatal screening
B. Developmental screening
C. Hearing and vision screening
D. Lead screening
4. Identify the specific features of disease prevention through immunization in childhood, including the diseases, the vaccines, the immunization schedule, the adverse effects of immunizations and the contraindications to immunization.	Lecture - ID Readings
5. Summarize the basic types of illness and injury prevention routinely provided to different ages.	Orientation Clerkship dir.sessions Clinic
6. Demonstrate the ability to provide anticipatory guidance about nutrition and behavior.	Orientation Clerkship dir. sessions Clinic

Readings: Berkowitz - Chapters 6-8 (12 pages); Bernstein and Shelov: Chapter 2 (36 pages); "Immunization" information in Supplemental Readings.

Study Guide Questions:

You are evaluating a two-day-old infant prior to discharge from the nursery. What advice would you give the parents regarding feeding, sleeping, and general care of their new baby?
A healthy ten-month-old is starting to cruise and pull himself up on furniture. What advice would you give the parents to make the house safe?
A six-month-old infant develops fever and then a generalized seizure eight hours following DTP and HIB immunizations. What are the considerations for modifying future immunizations?

II. Growth

Learning Objectives

1. Recognize abnormalities of growth which warrant further evaluation, such as crossing lines on a growth chart; discrepancies between height, weight and head circumference; short stature; failure to thrive; obesity; microcephaly and macrocephaly. Lecture - Endocrine

2. Recognize normal variants of growth, such as familial short stature and constitutional delay. Lecture - Endocrine

3. Outline the initial evaluation of a child with failure to thrive. Clerkship Dir. Sessions

4. Identify abnormal growth patterns and explain the initial assessment. Lecture - Endocrine

Readings:
Linder B. Short stature: etiology, diagnosis, and treatment. JAMA 260(1988):3171-75.
Krane EJ. Diabetic ketoacidosis: biochemistry, physiology, treatment, and prevention. Pediatric Clinics of North America 34(1987):935-57.
Bithoney WG, Dubowitz H, and Egan H. Failure to thrive/growth deficiency. Pediatrics in Review 13(1992):453-60.

Study Guide Questions:

The parents of an eight-year-old girl want to know how tall she will be. What will you tell them?

III. Development

Learning Objectives

1. Acquire basic knowledge of the appropriate developmental tasks of each stage of childhood and their importance in clinical care:

Infant - changes in reflexes, tone and posture; cephalocaudal progression of motor milestones during the first year; stranger anxiety
Toddler/child - separation and autonomy in two-to three- year-olds; concept of school readiness

Lecture - Development
Clerkship Dir. Sessions

2. Identify early signs of mental retardation and cerebral palsy. Lecture - Development

3. Perform and interpret the Denver Developmental Screening Test (DDST). Orientation

4. Identify children with language delay and discuss differential diagnosis. Lecture - Development

Readings: Berkowitz - Chapters 14-15 (10 pages)

Study Guide Questions:

The parents of a nine-month-old infant are concerned because she is not sitting. She has mildly increased tone and scissoring of her lower extremities. She can grasp a rattle, but does not reach for objects. She coos and has a social smile. What would you tell her parents?

IV. Behavior

Learning Objectives

1. Discuss the typical presentation of common behavioral problems at various developmental levels and ages (e.g., infant: sleep problems; toddler/preschool: temper tantrums, toilet training, eating problems; elementary school age: enuresis, attention deficit disorder; middle school/high school: conduct disorders, eating disorders, risk-taking behaviors). Clerkship Dir. Sessions

2. Recognize that somatic complaints may represent psychosocial problems (e.g., recurrent abdominal pain, headache, fatigue, and neurological complaints). Clerkship Dir. Sessions

3. Take a complete and relevant history and perform a pertinent physical examination on a patient who presents with a behavioral problem. Clinic

4. Distinguish between age-appropriate "normative" behavior and problem behavior. Clerkship Dir. Sessions

Readings: Berkowitz - Chapters 24-33 (27 pages); Bernstein and Shelov: Chapter 5 (8 pages).

Study Guide Questions:

A five-year-old boy is still wetting the bed at night. Discuss your approach to this.

The parents of a seven-year-old boy receive a call from the child's teacher because he is having difficulty following directions and behaving in class. She feels he has a short attention span. How should you proceed?

V. Nutrition

Learning Objectives

1. State the calories/kg/day needed for normal growth in infants and small children. Lecture - Feeding/Nutr.

2. Identify the major differences between human milk and commonly available formulas. Lecture - Feeding/Nutr.

3. Determine whether a formula-fed infant is receiving adequate calories. Lecture - Feeding/Nutr.

4. Describe the advantages of breast feeding and recognize common difficulties experienced by breast-feeding mothers. Lecture - Feeding/Nutr.

5. Discuss the nutritional advice to provide families regarding:

infant breast feeding vs. formula feeding
when solids are added to an infant's diet
use of cow's milk (low fat vs. whole; timing)

Lecture - Feeding/Nutr.

6. Discuss how to advise families about the prevention and treatment of iron deficiency. Lecture - Feeding/Nutr.

Readings: Berkowitz - Chapter 11 (5 pages); Bernstein and Shelov: Chapter 4 (pages 69-78). Supplemental Readings: Oski FA. Iron deficiency - facts and fallacies. Pediatric Clinics of North America 32(1985):493-97

Study Guide Questions:

A two-month-old is not growing or gaining weight. The baby is taking four ounces of formula every three or four hours. How would you evaluate if this intake is adequate?

A two-year-old girl eats a limited variety of food. What is your advice to her parents?

A one-year-old child is still drinking formula. Parents ask if they can transfer from formula to cow's milk. How would you counsel them?

VI. Issues Unique to Adolescence

Learning Objectives

1. Describe strategies for interviewing and counseling adolescents. Lecture - Adolescent

2. List the major causes of mortality and morbidity in adolescents. Lecture - Adolescent

3. Recognize the features of psychosocial and mental health problems common in adolescence, including school avoidance/ failure, eating disorders, depression and suicide. Lecture - Adolescent

Readings:
Anderson MM. Principles of care for the ill adolescent. Adolescent Medicine: State of the Art Reviews 2(1991):441-58.

Study Guide Questions:

A sixteen-year-old boy presents to your clinic with polyuria and weight loss over the past three weeks. Describe the important aspects of the history and physical exam, diagnostic considerations, differential diagnosis, and basic management principles.

The mother of a thirteen-year-old female expresses concern that her daughter has not yet had the onset of menses. How would you counsel her?

A fifteen-year-old boy is brought to your clinic by his twenty-one-year-old sister after threatening to "take a bunch of pills." He seems depressed in affect, and on initial evaluation is clinically stable. Explain your approach to this young man, including important history, physical exam findings, diagnostic studies, management principles, and advice to the parents.

VII. Issues Unique to the Newborn

Learning Objectives

1. Describe the important historical information, physical exam findings, and laboratory data helpful in developing the differential diagnosis for a newborn with the following presentations: Nursery
Readings

Table 1: Problems of Newborns

Clinical Problems Common Problems Significant Other Problems to Consider

Jaundice physiological jaundice
hemolytic disease
inadequate intake
systemic infection
hematoma biliary atresia
inborn metabolic disorders
hepatitis Lecture - Nursery

Respiratory Distress respiratory distress syndrome
transient tachypnea, pneumonia
meconium aspiration
sepsis congenital heart disease
pneumothorax Lecture - Nursery

Cyanosis cyanotic congenital heart disease
airway compromise
poor lung expansion
pulmonary disorders
acrocyanosis congenital pulmonary defects
diaphragmatic hernia
persistent pulmonary hypertension Lecture - Nursery

Jitteriness or Seizures drug withdrawal
hypoglycemia
hypocalcemia
perinatal asphyxia intracranial bleed
inborn metabolic disorders Nursery (ward faculty)
Readings

Lethargy or Poor Feeding sepsis
immaturity
perinatal asphyxia neuromuscular problems Nursery (ward faculty)
Readings

Hypoglycemia IDM (infant of a diabetic mother)
prematurity
small or large for gestational age
perinatal asphyxia hemolytic disease
polycythemia Nursery (ward faculty)
Readings

Sepsis bacterial infection
viral infection perinatal/ maternal infections
congenital infections (e.g., TORCH) Nursery (ward faculty)
Readings

Bilious Vomiting intestinal atresia
volvulus Clerkship Dir. Sessions
Readings

Non-bilious Vomiting overfeeding
gastroesophageal reflux esophageal atresia
sepsis
CNS problems
metabolic errors
pyloric stenosis Clerkship Dir. Sessions
Readings

* These diagnoses are not intended to be the limit of conditions to consider, but are to help students focus learning on key conditions.

2. Describe the special methods involved in performing a newborn physical examination (e.g., assessment of hip dysplasia, eye exam). Nursery Readings - EARLY!!

3. Identify the key concepts used in the clinical evaluation of gestational age and stability at birth (e.g., the Dubowitz exam and the Apgar). Use weight and gestational age to categorize potential clinical problems. Nursery (ward residents) Readings

4. Identify what medications are routinely given to all newborns (e.g., vitamin K, hepatitis B vaccine, ophthalmological prophylaxis). Readings

5. Discuss the effects of maternal alcohol, tobacco smoking, and illicit drug use. Readings

Readings:
(Optional): Bernstein and Shelov: Chapter 1 (16 pages)
Supplemental Readings: Jones KL. Fetal alcohol syndrome. Pediatrics in Review 8(1986):12226.
Chasnoff IJ. Newborn infants with drug withdrawal symptoms. Pediatrics in Review 9(1988):273-77.

Study Guide Questions:

The mother of a four-week-old infant phones at 10:00 p.m. and says her baby has had a temperature all day and that the fever is now 103 F. Describe important points of history, physical exam, diagnostic considerations, and basic management principles.

A baby is found to have a clavicular fracture after birth. The exam reveals crepitus and irregularity over the fracture, movement of the arm is painful, and the Moro reflex is absent on that side. Describe what you tell the parents about the problem and the expected prognosis.

A baby has an Apgar score of 5 at one minute and 9 at five minutes. Describe what this means.

A 24-hour old infant has not passed a meconium stool. Discuss possible explanations.

VIII. Common Pediatric Illnesses

Learning Objectives

Using the table of clinical presentations for each clinical problem (left hand column) develop a differential diagnosis and rationale assisted by conditions listed (middle and right hand columns).
Identify for each of the Common Problems and Significant Other Problems in the table (middle column):
- Etiology and/or pathophysiology
- Natural history of the disease
- Presenting signs and symptoms
- Initial laboratory test and/or imaging studies indicated for diagnosis
- Plan for initial management

Table 2: Common Acute Illnesses

Clinical Problems Common Problems Significant Other Problems to Consider

Cough upper respiratory infection
pneumonia
croup
bronchiolitis
bronchitis
asthma
sinusitis cystic fibrosis
pertussis
tuberculosis
foreign body aspiration
gastroesophageal reflux
chlamydia pneumonitis Lecture - ID
Clerkship Dir. Sessions
Clinic

Fever bacteremia occult
UTI - pyelonephritis
viral illness, nonspecific
viral exanthems: varicella
measles: fifth disease
roseola
scarlet fever osteomyelitis
meningitis
febrile convulsions
septic arthritis
Kawasaki's disease
juvenile rheumatoid arthritis
viral exanthem rubella
tuberculosis Clerkship Dir. Sessions
Clinic

Sore Throat pharyngitis, strep, scarlet fever
pharyngitis, other
mononucleosis rheumatic fever
cervical adenitis
peritonsillar and retropharyngeal abscesses Lecture - ID
Clinic

Otitis/Ear Pain otitis media
recurrent otitis media*
middle ear effusion deafness*
speech and language delay*
mastoiditis* Clinic
Readings

URI conjunctivitis
cellulitis*
allergic rhinitis
sinusitis periorbital/ orbital Lecture - ID
Clinic

Abdominal Pain appendicitis
UTI/ pyelonephritis
gastroenteritis
constipation
pelvic inflammatory disease
colic vasculitis (e.g., Henoch- Schonlein)
intussusception purpura
gastritis
pregnancy
encopresis*
inflammatory bowel disease
ulcer
ovarian/ testicular torsion
psychogenic abdominal pain
malignancy
incarcerated hernia Lecture - GI
Clerkship Dir. Sessions

Vomiting gastroesophageal reflux
pyloric stenosis
gastroenteritis
secondary to infections: strep
pharyngitis, otitis volvulus/bowel obstruction
diabetic ketoacidosis
increased intracranial pressure
hepatitis
pyelonephritis
pregnancy
congenital adrenal hyperplasia Lecture - GI
Clerkship Dir. Sessions

Diarrhea +/- Vomiting gastroenteritis
viral
bacterial
Giardia failure to thrive
hemolytic-uremic syndrome
dehydration* Lecture - GI
Clerkship Dir. Sessions
Clinic

Dermatitis/ Rash acute urticaria
atopic dermatitis
contact dermatitis
Monilial skin infections
scabies
impetigo/cellulitis
tinea infections anaphylaxis*
drug reaction rash
Stevens-Johnson syndrome
seborrheic dermatitis Lecture - Dermatology
Clinic

Trauma animal bite wounds
burns
child abuse tetanus*
rabies* Lecture - Toxicology

Joint/Limb Problems
tendonitis
infections: toxic tenosynovitis,
septic arthritis, osteomyelitis
congenital hip dislocation
injury nurse maid's elbow
arthritis (JRA)
sickle cell crisis
rheumatic fever
leukemia/tumors
Osgood-Schlatter disease
Legg- Calve- Perthes disease
slipped femoral capital epiphysis Clerkship Dir. Session
Readings
Clinic

CNS Problems headaches: migraine, tension
seizure disorders, febrile
convulsions
closed head trauma increased intracranial pressure, brain tumor
hydrocephalus Lecture - Neurology

* Important related condition, not directly a cause of the clinical problem.

Table 3: Significant Physical Findings

Clinical Problems Common Problems Significant Other Problems to Consider

Heart Murmur innocent murmurs
cardiac septal defects acute rheumatic fever
coarctation of the aorta
valvular stenosis Lecture - Cardiology
Readings

Lymphadenopathy infection- mononucleosis, bacterial
adenitis, viral infections Kawasaki's disease
lymphoma/ leukemia
HIV/AIDS
cat scratch disease Clinic
Readings

Splenomegaly systemic infection
mononucleosis tumor/ leukemia
hemolytic anemia
sickle cell disease Lecture - Heme-Onc

Hepatomegaly hepatitis congestive heart failure
cirrhosis Lecture - GI

Abdominal Mass constipation neuroblastoma
lymphoma
Wilms' tumor
hydronephrosis
intussusception Lecture - Heme-Onc

White Pupillary Reflex retinoblastoma
cataracts Nursery

Pallor/ Anemia iron deficiency anemia
lead poisoning hemolytic anemia: hereditary/ acquired
malignancy
sickle cell anemia
occult blood loss Lecture - Heme-Onc

Bruising/ Petechiae trauma
vasculitis hemophilia/Von Willebrand's
Henoch- Schonlein purpura
leukemia
secondary to infection/sepsis
thrombocytopenia
meningococcemia Lecture - Heme-Onc

Hematuria trauma
UTI acute glomerulonephritis (post-strep)
hemolytic-uremic syndrome
Henoch Schonlein purpura Lecture - Nephrology

Proteinuria orthostatic proteinuria nephrotic syndrome
glomerulonephritis Lecture - Nephrology

* Important related condition, not directly a cause of the clinical problem.

Readings: Berkowitz - Chapters 57-60, 62, 65-66, 76, 78-83 (59 pages)
Bernstein and Shelov: Chapters 7 (14 pages), 9-14 (136 pages), 17 (12 pages)
Supplemental Readings: Howle VM. Otitis media. Pediatrics in Review 14(1993):320-23.
Segel GB. Anemia. Pediatrics in Review 10(1988):77-88.
Manno CS. Difficult pediatric diagnoses: bruising and bleeding. Pediatric Clinics of North America 38(1991):637-55.
Freeman JM and Vining EPG. Decision making and the child with febrile seizures. Pediatrics in Review 13(1992):298-304.
Prensky AL. Differentiating and treating pediatric headaches. Contemporary Pediatrics 1(1984):12-45.

Study Guide Questions:

A one-month-old infant with a one-week history of cough and congestion now presents with paroxysms of cough associated with blue spells. The baby is afebrile. Exam of the chest is normal between coughs. Her WBC is 28,000 with 12S, 86L. CXR is normal. What is the likely etiology of her problem and how should she be cared for?

A fifteen-month-old was diagnosed with otitis media three weeks ago. Today on exam his tympanic membrane looks dull, gray, and has poor movement. What would you recommend next?

A six-year-old presents with fever and abdominal pain, bloody diarrhea and a few scattered petechiae. Discuss the differential diagnosis and approach to this patient.

An athletic 12-year-old boy complains of knee pain when running and playing soccer. Discuss the possible causes and management approach.

On a routine health supervision visit, a one year old boy is found to have Hgb 8.8, Hct 27 with MCV 68. Discuss your approach to the diagnosis and treatment of this child.

IX. Therapeutics

Learning Objectives

1. Explain how a drug dose is calculated for infants and prepubertal children. Ward
Clinic

2. List the most common generic types of medications used for management of the following uncomplicated conditions:

otitis media
wheezing
conjunctivitis
allergic rhinitis
urinary tract infection
impetigo
eczema
fever
streptococcal pharyngitis
acne
Clerkship Dir. Sessions
Clinic

3. Know how to treat simple and complicated cases of asthma. Lecture - Allergy/Immun.
Clerkship Dir. Sessions

Study Guide Questions:

A known asthmatic complains of worsening cough and wheezing, unresponsive to inhaled albuterol. What would you prescribe next?

A four-year-old girl has her first urinary tract infection. Urinalysis shows "many" WBC's and numerous motile rod-shaped bacteria on an unspun specimen. What medication (if any) would you prescribe?

A three-year-old has right otitis media and a fever of 38.8�C. How would you treat this?

X. Fluid and Electrolyte Management

Learning Objectives

1. Obtain historical information to assess state of hydration. Lecture - Fluids/Electr. Ward

2. Recognize the physical exam findings of dehydration. "

3. Calculate and write IV orders for maintenance fluid therapy. "

4. Calculate and write IV orders for rehydration of mild, moderate, and severe dehydration. Also for hyponatremic, hypernatremic, and normonatremic dehydration. "

5. Explain the clinical consequences of electrolyte disturbances, including hypernatremia and hyponatremia. Lecture - Fluids/Electr. Readings

6. Explain to parents how to use oral rehydration therapy for mild/moderate dehydration. Lecture - Fluids/Electr.Clinic

Study Guide Questions:

A six-year-old girl is admitted for elective surgery and is NPO. She weighs 28 kg. Write an order for her IV fluids prior to surgery.

A seven-month-old infant has had fever, vomiting, and diarrhea for the past 24 hours. How would you determine whether to admit the patient to the hospital for IV fluids or treat him as an outpatient?

A two-month-old infant is brought to the Emergency Department because of seizures. History reveals that he has had diarrhea for five days and has been fed only water and apple juice. What might be the cause of the seizures and how should they be treated?

Readings:
(Optional) Bernstein and Shelov: Chapter 4 (pages 78-90)

XI. Pediatric Emergencies (I)

Learning Objectives

1. Describe the clinical manifestations, toxicity, and basic management of ingestions of iron, lead, aspirin, acetaminophen, tricyclics, caustic agents and hydrocarbons, and exposure to carbon monoxide. Lecture - Toxicology

2. Know how/when to stop the absorption of an ingested substance. Lecture - Toxicology

3. Identify the environmental sources of lead and discuss the clinical and social impact of lead poisoning. Lecture - Toxicology

Study Guide Questions:

An eighteen-month-old boy is found in the garage coughing and choking. A jar of paint thinner is spilled on the floor and on his clothing. What advice would you give to the parents over the phone? Should they give Ipecac? What is the most serious toxicity of this ingestion/exposure?

Readings:
(Optional): Bernstein and Shelov: Chapter 15 (18 pages)

XII. Pediatric Emergencies (II)

Learning Objectives

1. Review of basic cardiopulmonary resuscitation and an understanding of treatment priorities in common pediatric emergencies such as near-drowning, choking, etc. Lecture - Critical Care

2. Recognize the different types of shock in children (hypovolemic, septic, cardiogenic, neurogenic). Lecture - Critical Care

3. For each condition listed in the right hand column of Table 4, provide the acute clinical presentation and initial diagnostic assessment. Lecture - Critical Care

Table 4: Acute Clinical Presentations

Acute Clinical Problem Diagnoses to Consider

Shock sepsis
meningococcemia
dehydration
diabetic ketoacidosis
burns
anaphylaxis
adrenal insufficiency (adrenogenital syndrome)
ingestion Lecture - Critical Care

Airway Obstruction/Respiratory Distress foreign body aspiration
anaphylaxis
epiglottitis
croup
asthma
bronchiolitis
pneumonia
peritonsillar or retropharyngeal abscesses Lecture - Critical Care

Apnea SIDS (sudden infant death syndrome)
ALTE (acute life threatening event)
seizure disorder
cardiac arrhythmia Lecture - Critical Care

Seizures febrile seizure
status epilepticus
epilepsy
ingestion (see Poisoning section)
toxic encephalopathy
increased intracranial pressure
electrolyte disturbances (sodium, calcium, glucose) Lecture - Neurology

Delirium/Coma head injury
substance abuse
infection (encephalitis, meningitis)
hepatic failure
Reye syndrome
diabetic ketoacidosis
hypoglycemia Lecture - Neurology

Readings: Berkowitz - Chapters 35-42 (30 pages); Bernstein and Shelov: Chapter 30 (20 pages)

Study Guide Questions:

A four-year-old girl with juvenile rheumatoid arthritis develops fever, deep labored breathing, vomiting, and diarrhea. She complains of ringing in her ears. Discuss the probable cause of these symptoms. What laboratory abnormalities would you expect to find?

The mother of an 18-month-old calls to say her child has pulled a hot cup of coffee down from the table which spattered across his face and chest. What are your recommendations?

A five-year-old boy presents with a dog bite to the cheek. How should this be cared for?

XIII. Child Abuse (Physical and Sexual)

Learning Objectives

1. List the physical and behavioral signs of physical abuse, sexual abuse, and neglect. Lecture - Child Abuse

2. List the risk factors for domestic violence and child abuse. Lecture - Child Abuse

3. Describe the specific types or patterns of injury that suggest physical abuse. Lecture - Child Abuse

4. List which family, social, and environmental history items are important when considering possible abuse. Lecture - Child Abuse

5. Summarize the physical findings expected in an infant who has been subjected to abuse by shaking (i.e., the shaken baby syndrome). Lecture - Child Abuse

6. Know the types of questions to ask in assessment of a child for non-accidental injuries and child abuse. Lecture - Child Abuse

Readings: (Optional) Berkowitz - Chapters 96-97 (7 pages)

Study Guide Questions:

A two-year-old presents to the emergency department after breaking her arm during a fall. The child was seen six months ago with a broken leg. What are your concerns? What evaluation should occur next?

A seven-year-old female patient presents with vaginal discharge. How would you approach the history and physical exam?

A two-month-old baby presents with lethargy and is poorly responsive. He has retinal hemorrhages on exam. Parents report that he "may have rolled off the couch." How would you proceed?

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Orientation - Health Supervision and Anticipatory Guidance

Length of Lecture: 1.5 hours

I.1. Describe the content of a health supervision visit and the factors used to determine the frequency of such visits.

I.3. Discuss the appropriate use and interpretation of the following screening tests:
A. Neonatal screening
B. Developmental screening
C. Hearing and vision screening
D. Lead screening

I.5. Summarize the basic types of illness and injury prevention routinely provided to different ages.

I.6. Demonstrate the ability to provide anticipatory guidance about nutrition and behavior.

III.3. Perform and interpret the Denver Developmental Screening Test (DDST).

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Endocrinology

Length of Lecture: 1.5 hours

II.1. Recognize abnormalities of growth which warrant further evaluation, such as crossing lines on a growth chart; discrepancies between height, weight, and head circumference; short stature; failure to thrive; obesity; microcephaly and macrocephaly.

II.3. Recognize normal variants of growth, such as familial short stature and constitutional delay.

II.5. Identify abnormal growth patterns and explain the initial assessment.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Child Development

Length of Lecture: 1 hour

III.1. Basic knowledge of the appropriate developmental tasks of each stage of childhood and their importance in clinical care:

Infant - changes in reflexes, tone, and posture; cephalocaudal progression of motor milestones during the first year; stranger anxiety
Toddler/child - separation and autonomy in two-to three-year-olds; concept of school readiness

III.2. Identify early signs of mental retardation and cerebral palsy.

III.4. Identify language delay in children.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Feeding and Nutrition

Length of Lecture: 1 hour

V.1. State the calories/kg/day needed for normal growth in infants and small children.

V.2. Identify the major differences between human milk and commonly available formulas.

V.3. Determine whether a formula-fed infant is receiving adequate calories.

V.4. Describe the advantages of breast feeding and recognize common difficulties experienced by breast-feeding mothers.

V.5. Discuss the nutritional advice to provide families regarding:

infant breast feeding vs. formula feeding
when solids are added to an infant's diet
use of cow's milk (low fat vs. whole; timing)

V.6. Discuss how to advise families about the prevention and treatment of iron deficiency.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Adolescent Medicine

Length of Lecture: 1 hour

III.1. Basic knowledge of the appropriate developmental tasks of each stage of childhood and adolescence and their importance in clinical care:

Adolescent - sequence of physical maturation and sexual maturity rating (Tanner); stages of emotional development

VI.1. Describe strategies for interviewing and counseling adolescents.

VI.2. List the major causes of mortality and morbidity in adolescents.

VI.3. Recognize the features of psychosocial and mental health problems common in adolescence, including school avoidance/failure, eating disorders, depression, and suicide.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Nursery

Length of Lecture: 1 hour

VII.1. Describe the important historical information, physical exam findings, and laboratory data helpful in developing the differential diagnosis for a newborn with the following presentations:

Clinical Problems Common Problems Significant Other Problems to Consider

Jaundice physiological jaundice
hemolytic disease
inadequate intake
systemic infection
hematoma biliary atresia
inborn metabolic disorders
hepatitis

Respiratory Distress respiratory distress syndrome
transient tachypnea, pneumonia
meconium aspiration
sepsis congenital heart disease
pneumothorax

Cyanosis cyanotic congenital heart disease
airway compromise
poor lung expansion
pulmonary disorders
acrocyanosis congenital pulmonary defects
diaphragmatic hernia
persistent pulmonary hypertension

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Allergy/Immunology

Length of Lecture: 1.5 hour

IX.3. Know how to treat simple and complicated cases of asthma.

IX.2. Know how to diagnose and treat allergic rhinitis.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Cardiology

Length of Lecture: 1 hour

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Dermatology

Length of Lecture: 1 hour

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Gastroenterology

Length of Lecture: 2 hours

VIII.1. Using the table of clinical presentations for each clinical problem (left-hand column) develop a differential diagnosis and rationale assisted by conditions listed (middle and right-hand columns).

VIII.2. Identify for each of the Common Problems and Significant Other Problems in the table:

Etiology and/or pathophysiology
Natural history of the disease
Presenting signs and symptoms
Initial laboratory test and/or imaging studies indicated for diagnosis
Plan for initial management

Clinical Problems Common Problems Significant Other Problems to Consider

Abdominal Pain appendicitis
UTI/ pyelonephritis
gastroenteritis
constipation
pelvic inflammatory disease
colic vasculitis (e.g., Henoch- Schonlein)
intussusception purpura
gastritis
pregnancy
encopresis
inflammatory bowel disease
ulcer
ovarian/testicular torsion
psychogenic abdominal pain
malignancy
incarcerated hernia

Vomiting gastroesophageal reflux
pyloric stenosis
gastroenteritis
secondary to infections: strep
pharyngitis, otitis volvulus/bowel obstruction
diabetic ketoacidosis
increased intracranial pressure
hepatitis
pyelonephritis
pregnancy
congenital adrenal hyperplasia

Diarrhea +/- Vomiting gastroenteritis
viral
bacterial
Giardia failure to thrive
hemolytic-uremic syndrome
dehydration

Hepatomegaly hepatitis congestive heart failure
cirrhosis

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Hematology-Oncology

Length of Lecture: 2 hours

Identify for each of the following:

Etiology and/or pathophysiology

Natural history of the disease

Presenting signs and symptoms

Initial laboratory test and/or imaging studies indicated for diagnosis

Plan for initial management

Clinical Problems
anemia
leukemia
lymphoma
neuroblastoma
Wilms' tumor
bleeding disorders

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Infectious Diseases (including Immunizations)

Length of Lectures: 3.5 hours (1 lecture=2 hrs; 1 lecture=1.5 hrs)

I.4. Identify the specific features of disease prevention through immunization in childhood, including the diseases, the vaccines, the immunization schedule, the adverse effects of immunizations, and the contraindications to immunization.

VIII.1. Using the table of clinical presentations for each clinical problem (left-hand column), develop a differential diagnosis and rationale assisted by conditions listed (middle and right- hand columns).

VIII.2. Identify for each of the Common Problems and Significant Other Problems in the table:

Etiology and/or pathophysiology
Natural history of the disease
Presenting signs and symptoms
Initial laboratory test and/or imaging studies indicated for diagnosis
Plan for initial management

Clinical Problems Common Problems Significant Other Problems to Consider

Cough upper respiratory infection
pneumonia
croup
bronchiolitis
bronchitis
asthma
sinusitis cystic fibrosis
pertussis
tuberculosis
foreign body aspiration
gastroesophageal reflux
chlamydia pneumonitis

Sore Throat pharyngitis, strep, scarlet fever
pharyngitis, other
mononucleosis rheumatic fever
cervical adenitis
peritonsillar and retropharyngeal abscesses

URI conjunctivitis
cellulitis*
allergic rhinitis
sinusitis periorbital/ orbital

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Nephrology

Length of Lecture: 1.5 hours

Clinical Problems Common Problems Significant Other Problems to Consider

Hematuria trauma
UTI acute glomerulonephritis (post-strep)
hemolytic-uremic syndrome
Henoch Schonlein purpura

Proteinuria orthostatic proteinuria nephrotic syndrome
glomerulonephritis

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Neurology

Length of Lecture: 2 hours

XII.3. For each condition listed in the right hand column of Table 4, provide the acute clinical presentation and initial diagnostic assessment.

Table 4: Acute Clinical Presentations

Acute Clinical Problem Diagnoses to Consider

Seizures febrile seizure
status epilepticus
epilepsy
ingestion (see Poisoning section)
toxic encephalopathy
increased intracranial pressure
electrolyte disturbances (sodium, calcium, glucose)

Delirium/Coma head injury
substance abuse
infection (encephalitis, meningitis)
hepatic failure
Reye syndrome
diabetic ketoacidosis
hypoglycemia

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Fluid and Electrolytes

Length of Lecture: 2 hours

X.1. Obtain historical information to assess state of hydration.

X.2. Recognize the physical exam findings of dehydration.

X.3. Calculate and write IV orders for maintenance fluid therapy.

X.4. Calculate and write IV orders for rehydration of mild, moderate, and severe dehydration. Also for hyponatremic, hypernatremic, and normonatremic dehydration.

X.5. Explain the clinical consequences of electrolyte disturbances, including hypernatremia and hyponatremia.

X.6. Explain to parents how to use oral rehydration therapy for mild/moderate dehydration.

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Pediatric Emergencies I - Toxicology

Length of Lecture: 1 hour

XI.1. Describe the clinical manifestations, toxicity, and basic management of ingestions of iron, lead, aspirin, acetaminophen, tricyclics, caustic agents and hydrocarbons, and exposure to carbon monoxide.

XI.2. Know how/when to stop the absorption of an ingested substance.

XI.3. Identify the environmental sources of lead and discuss the clinical and social impact of lead poisoning.

VIII.1. Using the table of clinical presentations for each clinical problem (left hand column) develop a differential diagnosis and rationale assisted by conditions listed (middle and right hand columns).

VIII.2. Identify for each of the Common Problems and Significant Other Problems in the table:

Etiology and/or pathophysiology
Natural history of the disease
Presenting signs and symptoms
Initial laboratory test and/or imaging studies indicated for diagnosis
Plan for initial management

Clinical Problems Common Problems Significant Other Problems to Consider

Trauma animal bite wounds
burns tetanus*
rabies*

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Pediatric Emergencies II - Critical Care

Length of Lecture: 1 hour

XII.1. Review of basic cardiopulmonary resuscitation and an understanding of treatment priorities in common pediatric emergencies such as near-drowning, choking, etc.

XII.2. Recognize the different types of shock in children (hypovolemic, septic, cardiogenic, neurogenic).

XII.3. For each condition listed in the right hand column of Table 4, provide the acute clinical presentation and initial diagnostic assessment.

Table 4: Acute Clinical Presentations

Acute Clinical Problem Diagnoses to Consider

Shock sepsis
meningococcemia
dehydration
diabetic ketoacidosis
burns
anaphylaxis
adrenal insufficiency (adrenogenital syndrome)
ingestion

Airway Obstruction/Respiratory Distress foreign body aspiration
anaphylaxis
epiglottitis
croup
asthma
bronchiolitis
pneumonia
peritonsillar or retropharyngeal abscesses

Apnea SIDS (sudden infant death syndrome)
ALTE (acute life threatening event)
seizure disorder
cardiac arrhythmia

Third-year Medical Students
Core Curriculum: Weekly Lecture Series

Child Abuse

Length of Lecture: 1.5 hours

XIII.1. List the physical and behavioral signs of physical abuse, sexual abuse, and neglect.

XIII.2. List the risk factors for domestic violence and child abuse.

XIII.3. Describe the specific types or patterns of injury that suggest physical abuse.

XIII.4. List which family, social, and environmental history items are important when considering possible abuse.

XIII.5. Summarize the physical findings expected in an infant who has been subjected to abuse by shaking (i.e., the shaken baby syndrome).

XIII.6. Know the types of questions to ask in assessment of a child for non-accidental injuries and child abuse.

Clerkship Director Sessions (9 hours)

Session 1. Fever

Session 2. Newborn Sepsis

Session 3. Cough

Session 4. Diarrhea/Vomiting/Abdominal Pain

Session 5. Failure to Thrive, Behavior & Development

Session 6. Joint/Limb Problems

Each session will be 1.5 hours in length: 60-75 minutes will be spent on a lecture/discussion on the weekly topic. The rest will be spent on student case presentations.

Clinic Learning Objectives

(Note: numbering of topics corresponds to Learning Objectives)

I. Health Supervision

2. Gather health supervision data from a focused history and physical examination.

5. Summarize the basic types of illness and injury prevention routinely provided to different ages.

6. Demonstrate the ability to provide anticipatory guidance about nutrition and behavior.

IV. Behavior

3. Take a complete and relevant history and perform a pertinent physical examination on a patient who presents with a behavioral problem.

VIII. Common Pediatric Illnesses

1. Using the table of clinical presentations for each clinical problem (left hand column) develop a differential diagnosis and rationale assisted by conditions listed (middle and right hand columns).

2. Identify for each of the Common Problems and Significant Other Problems in the table (middle column):

Etiology and/or pathophysiology

Natural history of the disease

Presenting signs and symptoms

Initial laboratory test and/or imaging studies indicated for diagnosis

Plan for initial management

Table 2: Common Acute Illnesses

IX. Therapeutics

Explain how a drug dose is calculated for infants and prepubertal children.

List the most common generic types of medications used for management of the following uncomplicated conditions:

otitis media
wheezing
conjunctivitis
allergic rhinitis
urinary tract infection
impetigo
eczema
fever
streptococcal pharyngitis
acne

X. Fluid and Electrolyte Management

6. Explain to parents how to use oral rehydration therapy for mild/moderate dehydration.

Ward Learning Objectives

(Note: numbering of topics corresponds to Learning Objectives)

The major focus of the ward rotation is to provide you with experience in performing detailed history and physical examinations, developing problem lists and differential diagnoses, presenting cases orally and in written form, and writing daily progress notes (please see the General Clerkship Goals and Objectives on p. 4 of this syllabus).

In addition, you should be doing general reading about your own patients. Listed below are a few specific skills and areas of knowledge that you should also master while on the ward rotation.

IX. Therapeutics

1. Explain how a drug dose is calculated for infants and prepubertal children.

X. Fluid and Electrolyte Management

1. Obtain historical information to assess state of hydration.

2. Recognize the physical exam findings of dehydration.

3. Calculate and write IV orders for maintenance fluid therapy.

4. Calculate and write IV orders for rehydration of mild, moderate, and severe dehydration. Also for hyponatremic, hypernatremic, and normonatremic dehydration.

Nursery Learning Objectives

(Note: numbering of topics corresponds to Learning Objectives)

VII. Issues Unique to the Newborn

1. Describe the important historical information, physical exam findings, and laboratory data helpful in developing the differential diagnosis for a newborn with the following presentations:

Table 1: Problems of Newborns

Clinical Problems Common Problems Significant Other Problems to Consider

Jaundice physiological jaundice
hemolytic disease
inadequate intake
systemic infection
hematoma biliary atresia
inborn metabolic disorders
hepatitis

Respiratory Distress respiratory distress syndrome
transient tachypnea, pneumonia
meconium aspiration
sepsis congenital heart disease
pneumothorax

Cyanosis cyanotic congenital heart disease
airway compromise
poor lung expansion
pulmonary disorders
acrocyanosis congenital pulmonary defects
diaphragmatic hernia
persistent pulmonary hypertension

Jitteriness or Seizures drug withdrawal
hypoglycemia
hypocalcemia
perinatal asphyxia intracranial bleed
inborn metabolic disorders

Lethargy or Poor Feeding sepsis
immaturity
perinatal asphyxia neuromuscular problems

Hypoglycemia IDM (infant of a diabetic mother)
prematurity
small or large for gestational age
perinatal asphyxia hemolytic disease
polycythemia

Sepsis bacterial infection
viral infection perinatal/ maternal infections
congenital infections (e.g., TORCH)

* These diagnoses are not intended to be the limit of conditions to consider, but are to help students focus learning on key conditions.

2. Describe the special methods involved in performing a newborn physical examination (e.g., assessment of hip dysplasia, eye exam).

3. Identify the key concepts used in the clinical evaluation of gestational age and stability at birth (e.g., the Dubowitz exam and the Apgar). Use weight and gestational age to categorize potential clinical problems.

Clinical Problems Common Problems Significant Other Problems to Consider

White Pupillary Reflex retinoblastoma cataracts

Clinic Responsibilities

Ambulatory Pediatric Rotation at CHS (2 weeks)

Your role as a clinical clerk is to function as a physician in an ambulatory setting. The main task is to obtain a thorough history, perform a careful physical examination, formulate a differential diagnosis, order appropriate studies, initiate needed treatment, and work out a disposition. All of this is done under the supervision and in consultation with attending physicians or pediatric residents.

The approach to each patient is to be as comprehensive and prevention-minded as possible, inquiring into the child's general progress, immunization status, etc. Also, the student should inquire closely about siblings and other family members who may have health problems in need of attention. Environmental and social histories are important parts of the medical history and often contribute very significantly to the etiology or severity of the child's health problem.

A number of ancillary professionals are available within the Children's Health Center who should be used to advantage in helping care for a child. These are the pediatric nurse practitioner, a dietitian, and a social worker. We also have a multidisciplinary clinic for children with learning disorders.

Olive View Medical Center Rotation (2 weeks)

To see ambulatory care in a variety of settings, students are assigned for two weeks to Olive View Medical Center in Sylmar to gain experience with indigent patients who present with a wide variety of common infections and illnesses. During the time at Olive View students will attend the Acute Care Clinic, selected subspecialty clinics, and the newborn nursery.

Ward Responsibilities

Inpatient Rotation (2 weeks)

Initial Work-up

Student will usually be assigned to the General Pediatrics service. Students are responsible for doing histories and physical examinations, working jointly with the housestaff in the evaluation and management of the patient's problems. Students should try to perform as many work-ups as possible. A minimum target of 3-4 per week is recommended. The student's work-up becomes an official part of the medical record. The student's work-up is often the most complete version and is extremely helpful in the diagnosis and care of the patient. The student is expected to write a "discussion" at the end of each write-up to demonstrate that he or she has formulated a differential diagnosis of the patient's illness. The student is on the night call schedule with one of his/her interns and is required to remain all night (every fourth night). The student will have one day off each weekend while on the ward.

Follow-up and Progress Notes

Students must follow the daily course of each of their patients in the hospital and write daily progress notes in the chart. It is good practice to examine each patient and the chart first thing in the morning before the regular business of the day begins.

The essence of a good progress note is a description of clinical phenomena and their diagnostic or therapeutic implications.

Talking with Patients/Parents

Communication with patients is an essential part of any diagnostic and therapeutic process. The late Sir James Spence, an eminent pediatrician, wrote that his medical students "...are told that before explanations and advice can be given to a patient they must make three diagnoses - the diagnosis of the disease, the diagnosis of the concept or fears of the disease in the mind of the patient or parents, and, thirdly, the diagnosis of the patient's capacity to understand the explanations (at the child's level) and to follow the advice."

We encourage you to take the time to talk with patients and parents to understand their feelings better and how they perceive what is happening in the hospital. The more you communicate with patients, however, the more often you find yourself in the uncomfortable spot of not knowing how much or what to say. Patients or parents of sick children are frequently under great stress. At times, their anxiety compels them to buttonhole whomever they can to pump for information that might ease their worry or resolve uncertainty. Coordinate your answers or statements with the primary care giver, whether housestaff or private physician, as nothing is more anxiety-provoking to parents than conflicting stories.

Evaluation

The clinical performance during the clerkship constitutes the largest part of your pediatric course grade. You will be evaluated by the attending physicians and senior house officers at the end of each rotation. Consideration is given to:

Your ability to apply your basic medical knowledge to patient problems.
Your skill in performing a history and physical examination.
Your ability to critically evaluate and integrate data in seeking solutions to identified problems.
Your interest in and responsibility for patient care.
Your ability to work and communicate with other staff.
Your ability to establish rapport with patients.
Your participation in conferences.
Your general inquisitiveness, consistency, and responsibility.

At the end of the clerkship, students will take the Pediatric Clerkship Exam and the NBME Shelf Exam in Pediatrics. Pass/Fail status will be based on clinical performance and the Pediatric Clerkship Exam. In order to pass the clerkship, the student must pass both the clinical performance component of the clerkship and the Pediatric Clerkship Exam. The NBME will be used as a measure of knowledge gained during the clerkship, but will not be used in determining Pass/Fail status in the clerkship.

Attendance Policy:

All absences must be made up. Your team senior should be notified in advance if you plan to be absent. For each day that a student misses from the rotation, arrangements must be made with the clerkship director to make up the time. A student may miss 3 days of this rotation without risk of repeating the entire rotation. If a student misses more than 3 days, the student may be asked to repeat the rotation at the clerkship director's discretion.

Students are expected to comply with the weekend schedules of the clerkship. Students should have one day off a week (this day may not necessarily be on a weekend), averaged over the entire clerkship.