SKILLS

Rationale
Prerequisites
General Competencies
Specific Skills

Rationale
An essential skill for success as a clinician and lifelong learner is clinical problem solving. The process of going from a patient's chief complaint to the creation of an appropriate differential diagnosis and the formulation of a diagnostic therapeutic plan is the core of clinical medicine. Skills essential for competent medical care include the ability to conduct an interview, perform a physical examination, manage medical data, communicate written and oral information, integrate basic science knowledge, search and read the literature critically, and teach. The care of individual patients requires the application of all of these skills.

Prerequisites

• Introductory course in physical diagnosis which includes general physical examination techniques and the use of diagnostic instruments.
• Basic competency in patient interviewing to include an understanding of different styles of questions used in the medical review, such as open-ended, directed, follow-up, and summary questions.
• Awareness of the affects of personal and cultural differences in the provision of care.

General Competencies (all skills are CP unless specifically designated U or M)

1. Demonstrate sensitivity to confidentiality, privacy, and modesty, during the medical interview and physical examination (U) (see professionalism)
2. Demonstrate an ability to perform an age-appropriate history and physical examination in children of all ages (CP)

Specific Skills:

A. Interviewing Skills

1. Demonstrate an ability to obtain the following information in an age-appropriate and sensitive manner from a child and or the accompanying adult: (CP)

   Past History

   • Neonatal history, including:
   • Birth weight and approximate gestational age
   • Maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications
   • Problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections
   • Immunizations
   • Previous hospitalizations (U)
   • Surgeries (U)
   • Medications and medication allergies (U)
   • Chronic medical conditions (U)
   • Growth and development
   • Nutrition (U)
     
     
   Family History:
   
   
   • Age and health of family members to include acute and chronic medical conditions (U)
   • Drug and alcohol abuse (U)
   • Construct a family pedigree
     
     

   Social History:

   • Household composition and socioeconomic status (U)
   • School, caregiver, and peer relationships (U)
   • HEADSS assessment
   • Environmental and Personal Safety Assessment:
   • Seat belts and car seats
   • Bicycle helmets
   • Firearms in the home
   • Smoking (U)
   • Lead exposure
   • Home safety for infants and toddlers

B. Physical Examination Skills

1. Demonstrate the role of patient observation in determining the nature of a child's illness and developmental stage (CP)
2. Conduct a pediatric physical examination appropriate to the nature of the visit or complaint (complete vs. focused) (U) and the age of the patient (CP)
3. Demonstrate an ability to perform the following examination skills (CP)
   
   Appearance
   
   
   • Interpret the general appearance of the child, including size, morphologic features, development, behaviors and interaction of the child with the parent and examiner.
   • Identify signs of acute and chronic illness in a neonate, infant, toddler, school aged child, and adolescents as evidenced by skin color, respiration, hydration, mental status, cry and social interaction.
     
     
   Vital signs
   
   
   • Measure vital signs, demonstrating knowledge of the appropriate blood pressure cuff size and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic)
   • Identify variations in vital signs based on age of the patient, the presence or absence of disease, and testing modalities (e.g. blood pressure cuff size).
     
     

   Growth (See section on Growth)

   • Accurately graph and interpret height (length), weight, and head circumference
   • Calculate, plot, and interpret BMI (U)
   • Describe the usefulness of longitudinal data in assessing growth
     
     

   Development (See section on Development)

   • Accurately identify and interpret major developmental milestones of the neonate, infant, toddler, school-aged child, and adolescent.

   HEENT
   
   
   • Observe, measure, and describe head size and shape, symmetry, facial features, and ear position as part of the examination for dysmorphic features
   • Identify sutures and fontanels in neonates and interpret the findings.
   • Identify the red reflex and discuss how it is used to detect corneal opacities and intraocular masses.
   • Detect the corneal light reflection and discuss how it is used to identify strabismus
   • Assess hydration of the mucous membranes.
   • Assess dentition (U)
   • Observe the tympanic membrane using an otoscope and an insufflator
   • Identify the structures of the oropharynx (e.g. uvula, tonsils, palate, tongue) and recognize signs of pathology (U)
     
     
   Neck
   
   
   • Palpate lymph nodes and describe what anatomic areas they drain (U)
   • Demonstrate maneuvers that test for nuchal rigidity
   • Palpate the thyroid and any neck masses (U)
     
     

   Chest

   • Observe, measure and interpret the rate, pattern and effort of breathing (U)
   • Identify normal variations of respiration and signs of respiratory distress e.g. grunting, flaring, and retraction (U)
   • Identify normal breath sounds and findings consistent with respiratory pathology such as stridor, wheezing, crackles and asymmetric breath sounds (U)
   • Identify transmitted upper airway sounds (U)
   • Observe and describe breast tissue according to developmental stage (e.g. Tanner scale) (CP) and palpate breast tissue (M)
     
     
   Cardiovascular
   
   
   • Identify the pulses in the upper and lower extremities through palpation.
   • Observe and palpate precordial activity (U).
   • Describe cardiac rhythm, rate, and quality (such as intensity, pitch, and location) of the heart sounds and murmurs and variation with maneuvers through auscultation. (U)
   • Assess peripheral perfusion, using a test for capillary refill. (U)
   • Identify central versus peripheral cyanosis
     
     
   Abdomen
   
   
   • Palpate the liver, spleen and kidneys, and interpret the finding based on the age of the patient.
   • Assess the abdomen for distention, tenderness, and masses through observation, auscultation, and palpation (U)
   • Determine the need for a rectal examination, (CP) and demonstrate the age-appropriate technique (M).
     
     
   Genitalia
   
   
   • Describe the difference in appearance of male and female genitalia at different ages and developmental (e.g. Tanner) stages.
   • Palpate the testes (CP) and identify genital abnormalities in males, including cryptorchidism (CP), hypospadias, phimosis, hernia, hydrocele and testicular mass (M).
   • Recognize genital abnormalities in females including signs of virilization (CP) imperforate hymen, labial adhesions and signs of injury.(M)
     
     
   Extremities
   
   
   • Examine the hips of a newborn for developmental dysplasia of the hip using the Ortolani and Barlow maneuvers
   • Observe and describe the gait of children at different ages.
   • Identify age-related variations in the examination of the extremities, such as tibial torsion, genu valgus, flat feet, etc. (M)
   • Recognize pathology, such as joint effusions, signs of trauma, and inflammation(CP) and restricted or excessive joint mobility (M)
     
     

   Back

   • Perform and interpret a screening test for scoliosis.
   • Examine the back for midline tufts of hair, pits, sacral dimples, or masses.
     
     
   Neurologic examination
   
   
   • Elicit the primitive reflexes that are present at birth and describe how they change as the child develops.
   • Assess the quality and symmetry of tone, strength and reflexes, using age-appropriate techniques. (M)
   • Assess the major developmental milestones of newborns, infants, toddlers, school aged, children, and adolescents.
     
     
   Skin
   
   
   • Describe and assess turgor, perfusion, color, hypo and hyperpigmented lesions, and rashes through observation and palpation (U)
   • Identify jaundice, petechiae, purpura, bruising, vesicles, and urticaria. (U)

C. Patient Communication Skills

1. Conduct an effective interview by adapting the interview to the visit (e.g., first visit, acute care, health supervision), or chief complaint, (U)
2. Demonstrate effective verbal and non-verbal communications skills with children and their parents or families that include:
• Establishment of rapport taking into account the patient's age and development stage (CP)
• Use of communication techniques that enable development of a therapeutic alliance being sensitive to the unique social condition and cultural background of the family (U)
• Identification of the primary concerns of the patient and/or family (U).
• Discussion of medical information in terms understandable to patients and families avoidance of medical jargon (U)
3. Correctly identify the need for an interpreter in specific patient-physician interactions. (U)
4. Effectively communicate information about the diagnosis, diagnostic plan, and treatment to the patient and family and assess the patient and families understanding (M).
5. Describe the important role of patient education in treatment of acute and chronic illness, and prevention of disease. (M)
6. Observe and reflect on the communication of "bad news" to parents, children and adolescents. (M)

D. Peer Communication Skills

1. Demonstrate effective oral and written communication with the health care team avoiding jargon and vague terms (e.g. clear and normal). (U).
2. Present a complete, well-organized verbal summary of the patient's history and physical examination findings, including an assessment and plan modifying the presentation to fit the time constraints and educational goals of the situation. U
3. Document the history, physical examination, and assessment and plan using a format appropriate to the clinical situation (e.g., inpatient admission, progress note, office or clinic visit, acute illness, health supervision visit, and interval care visits). (U)
4. Write admission and daily orders for a hospitalized patient (U)
5. Write a prescription (see Therapeutics section) (U) specific for a child's weight (CP)

E. Problem solving skills

1. Demonstrate an ability to generate an age-appropriate differential diagnosis and problem list based on the interview and physical examination. (CP)
2. Outline a diagnostic plan based on the differential diagnosis, and justify the diagnostic tests and procedures taking into account the test's sensitivity, specificity, and predictive value, as well as its invasiveness, risks, benefits, limitations, and costs. (MU)
3. Interpret the results of diagnostic tests or procedures, recognizing the age-appropriate values for commonly used laboratory tests, such as the CBC, urinalysis, and serum electrolytes. (M)
4. Formulate a therapeutic plan appropriate to the working diagnosis (MU)
5. Formulate an educational plan to inform the health care team and family of your thought process and decisions. (MU)
6. Search for relevant information using electronic (or other) data bases and critically appraise the information obtained to make evidence based decisions. (U)