Pediatric Clerkship Module

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PEDIATRIC CLERKSHIP MODULE

Placement in curriculum: Final Year

Module code:

Module Duration: 03 weeks

Pre requisite: All Modules of the First and Second Spiral

Module Team

Chairman Curriculum Committee Prof. Masood Anwar

Module Planner Prof. Samiya Naeemullah

Associate Director Education Dr. Rahila Yasmeen

Assistant Dean Medical Education Dr. Rehan Ahmed Khan

Module Coordinator Dr. Mahwish Rabia, Dr. Asma Shabbir

Clinical Curriculum Committee

members

Dr. Shams un Nisa Sadia, Dr. Asma Shabbir, Dr. Asim

Zulfiqar,

Clinical Teaching Team Prof. Samiya Naeem Ullah, Prof. Tahir Ch. Dr. Mahwish,

Dr. Asma

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Introduction/ Rationale

Pediatrics is the discipline concerned with all aspects of the well being of

infants and children including their health, their physical, mental and

psychological growth and development and their opportunity to achieve

full potential as adults. The young are also among the most vulnerable and

their needs require special attention.

The pediatric clerkship is designed to provide the final year student with an

opportunity to apply their knowledge of the common pediatric domains

including preventive pediatrics, common neonatal problems, infectious

diseases and other common systemic illnesses.

The aim of this clerkship is to train the final year students in neonatal and

pediatric history taking and physical examination. They are expected to

diagnose, investigate and treat common pediatric illnesses and

appropriately refer patients for specialized care when necessary. They also

need to focus on special needs of sick patients like fluid requirements and

calculation of drug doses.

Learning Outcomes

By the end of the clerkship the students should be able to:

Apply the basic concepts of pediatrics formed in 1st and 2nd Spiral

modules to solve common pediatric clinical problems.

Demonstrate proficiency in taking age appropriate history and

performing neonatal and pediatric clinical examination.

Interpret investigations of common pediatric diseases.

Diagnose and treat common pediatric problems.

Recognize a sick child and provide initial management to a critically

ill child.

Communicate effectively with the patient and/or care givers.

Educate the patients/ caregivers regarding disease prevention,

nutrition and immunization.

Calculate the age and weight appropriate fluid requirement and

medication doses of pediatric patients.

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CORE CLINICAL PROBLEMS OBSTETRICS

CORE CLINICAL PROBLEM

KNOWLEDGE SKILLS ATTITUDE

History taking, investigations treatment, complications and follow-up

C1- Remember C2 Understand C3- Apply C4- Analyse C5- Evaluate C6- Create

P1 Observation P2 Perform under direct supervision P3 Perform under indirect supervision P4 Perform independent

A1 reaction A2 response A3 internalization

Growth and development

Normal developmental milestones C4 Normal growth and Growth retardation C4 Micro and macrocephaly C4

Anthropometric measurements P4 Use of growth charts P4

Preventive pediatrics

Normal nutritional requirements C4 Malnutrition C4

History and Examination of a child with malnutrition P3 Making a feeding chart P3

Neonatology Care of normal newborn C4 Prematurity C4 Sepsis C4 Jaundice C4 Respiratory distress C4 Infant of diabetic mother C4

History and Examination of newborn P4 Neonatal resuscitation P2

Medical Genetics and Congenital Malformations

Chromosomal abnormalities (e.g. Trisomy 21) C4 Congenital malformations (e.g. Spinal bifida)C4

Examination of Down‟s syndrome patient P4

Counseling of a patient with Downs syndrome

Fever Urinary tract infection C4 Enteric fever C4 Malaria C4 Tuberculosis C4 Mumps C4 Rheumatic fever C4 Meningitis C4

History and clinical examination of a patient with fever C4

Counseling

Rash Chicken pox C4 Measles C4 Scarlet fever C4 Meningococcemia C4

History and clinical examination of a patient with rash C4

4

Cough Pneumonia C4 WHO ARI protocol C4 Pulmonary tuberculosis C4 Bronchiolitis C4 Bronchial Asthma C4

History and Examination of respiratory system P4

Counseling of patient with bronchial asthma A2

Diarrhoea

Acute diarrhea C4 WHO diarrhoea protocol C4 Fluid requirement for dehydration C4 Chronic diarrhea C4

History of patient with diarrhoea C4 signs of dehydration P4

Counseling

Jaundice Viral hepatitis C4 Chronic liver disease Wilson disease C3

History of a patient with jaundice C4 Examination of gastrointestinal

system P4

Counseling

Seizures Febrile convulsions C4 Epilepsy C3 Metabolic seizures C4

History of a patient with seizures C4 Examination of central nervous system P4

Mental retardation Cerebral Palsy C4 History and examination of patient with cerebral palsy P4

Murmur Acyanotic congenital heart disease (VSD, PDA) C4 Cyanotic congenital heart disease (TGA, TOF) C4 Rheumatic heart disease C4

History of a patient with congenital / acquired heart disease C4 Examination of cardiovascular system P4

Oedema Post streptococcal acute Glomerulonephritis C4 Nephrotic syndrome C4

History and Examination of a patient with oedema P3

Pallor/anemia Iron deficiency anemia C4 Megaloblastic anemia C3 Thalassemia C4

Examination of a patient with aneamia P4

Counseling a patient of thalassemia A2

Bruising/petechiae Hemophilia C4 Henoch-Schonleinpurpura C2 Leukemia C3 Idiopathic Thrombocytopenicpurpura C4

History and clinical examination of a patient with bruising/ bleeding C4

Endocrine disorders

Hypothyroidism C4

History and examination of a patient with hypothyroid child

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TABLE OF SPECIFICATION

CORE CLINICAL PROBLEM

KNOWLEDGE PSYCOMOTOR SKILLS ATTITUDE %age

Growth and development

4 3 - 7

Preventive pediatrics 6 3 - 9

Neonatology 4 2 - 6

Genetics and dysmorphology

1 1 1 3

fever 5 4 1 10

Rash 3 3 - 6

Cough 5 3 1 9

Diarrhoea 4 3 1 8

Jaundice 3 3 1 7

Seizure 4 3 7

Mental retardation 2 1 - 3

Murmur 4 3 - 7

Anemia 2 2 1 5

Oedema 3 2 - 5

Bruising/ petechiea 3 2 - 5

Endocrine disorder 2 1 - 3

Total 55 39 6 100

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GROWTH AND DEVELOPMENT

Knowledge Learning Objectives Instructional strategy Assessment Tool

Describe the developmental

domains of childhood (gross motor,

fine motor, language and social

development) and normal growth

pattern

Interactive tutorial MCQ

Differentiate between various diseases resulting in

deviation from normal growth and

developmental patterns according

to age (short stature, obesity,

microcephaly, macrocephaly)

CBD MCQ

Skills Learning Objectives Instructional strategy Assessment Tool

Take an appropriate history of a child with developmental delay

Case presentation Structured

Long case

Perform a developmental assessment of a child at a given age

Clinical method OSCE

perform anthropometric measurement and plot height,

weight and head circumference on age appropriate charts.

Clinical methods/

skill lab

OSCE

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PREVENTIVE PEDIATRICS


Classify the degree of malnutrition in a malnourished child

CBD/ ward round MCQ

Differentiate between clinical features of kwashiorkor and marasmus on a patient

CBD/ ward round MCQ

Devise a plan for management of a malnourished child

CBD MCQ


Obtain a history in a malnourished child at a given age

Case discussion Structured

long case

Perform a clinical examination of a malnourished child

Clinical

examination

OSCE

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NEONATOLOGY Knowledge

Learning Objectives Instructional strategy Assessment Tool

Discuss causes, complications and management of a preterm/low birth weight neonate

CBD MCQ

Discuss the causes and pathophysiologies of neoatal jaundice and neonatal sepsis

CBD MCQ

Interpret investigations required for neoatal jaundice and neonatal sepsis

CBD MCQ

Outline treatment plan of neoatal jaundice and neonatal sepsis

CBD MCQ


Demonstrate history taking of a neonate

Case discussion Structured

long case

Perform a complete clinical examination of a neonate

Clinical

examination

OSCE

Demonstrate steps of neonatal resuscitation on a dummy

Skill lab OSCE

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MEDICAL GENETICS AND DYSMORPHOLOGY Knowledge


Describe the chromosomal abnormality and clinical features of trisomy 21

CBD MCQ

Discuss the etiology, clinical features and management of spina bifida

CBD MCQ


Perform physical examination of a child with Downs Syndrome

Clinical examination OSCE

Attitude Learning Objectives Instructional strategy Assessment Tool

Counsel the parents of a child with Down ‟s Syndrome

Role play OSCE

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FEVER Knowledge


Discuss the differential diagnosis of patient with fever ( urinary tract infection, Enteric fever, Malaria, meningitis, Rheumatic fever, Tuberculosis)

CBD MCQ

Interpret the results of investigation of a patient with fever

CBD MCQ

Devise the management plan of a patient with fever depending upon underlying cause

CBD MCQ


Take a comprehensive history of patient with fever

Case presentation Structured Long case

Perform a detail clinical examination of a patient with fever

Clinical methods Structured Long case/ OSCE


Counsel the parents of a child with fever

Role play OSCE

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RASH Knowledge


Discuss the differential diagnosis of a Pediatric patient according to appreance of rash (measles, chicken pox, scarlet fever and meningococcemia)

CBD MCQ

Describe the complication and prevention of rash producing diseases

CBD MCQ

Interpret the result of investigation in a patient with rash

CBD MCQ

Discuss the management plan according to type of rash

CBD MCQ


Take a detail history of a patient with

rash

Case presentation Structured long case

Perform a clinical examination of a

patient with rash


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COUGH Knowledge


Discuss differential diagnosis of a Pediatric patient having cough on the basis of clinical features neumonia, bronchiolitis, bronchial Asthma, Pulmonary Tuberculosis)

CBD MCQ

Discuss WHO ARI classification CBD MCQ

Interpret the result of investigations of patient having cough

CBD MCQ

Outline the management plan of the patient having cough depending upon their underlying diagnosis

CBD MCQ


Take a comprehensive history of a pediatrics patient with cough


Perform a respiratory system examination of a patient with cough



Counsel/ educate a patient with Bronchial Asthma

Role play OSCE

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DIARRHEA Knowledge


Discuss differential diagnosis in a patient with acute diarrhea on the basis of etiology and clinical features

Case presentation MCQ

Discuss differential diagnosis in a patient with chronic diarrhea on the basis of etiology and clinical features


Discuss WHO classification of dehydration and its management


Interpret the result of investigation with diarrhoea


Devise a management plan of a patient with diarrhoea



Take a detail history of a pediatric patient with acute/ chronic diarrhoea


Examine a patient for signs of dehydration



Counsel the parents of a child with acute diarrhoea

Role play OSCE

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JAUNDICE Knowledge


Discuss the differential diagnosis of jaundice depending upon their acute

liver disease children

CBD/ward round MCQ

Discuss the differential diagnosis of

jaundice depending upon their chronic liver disease in children

CBD/ward round MCQ

Interpret the result of investigation of a patient with jaundice

CBD/ward round MCQ

Out line the treatment plan of a patient with jaundice depending upon their underlying cause

CBD/ward round MCQ


Take a detail history of a patient with jaundice


Examine a patient with jaundice Clinical examination OSCE


Counsel the parents of a jaundiced child

Role play OSCE

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SEIZURES Knowledge


Discuss the differential diagnosis of a seizure in childhood (febrile seizures, epilepsy, CNS infections, SOL)

CBD/case presentation MCQ

Interpret the results of investigations of a patient with seizures.


Outline the treatment plan of seizures according to underlying cause



Take a history of a patient with seizures disorder


Perform central nervous system examination of patient with seizures disorder


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MENTAL RETARDATION Knowledge


Describe etiology ,pathophysiology, and clinical features of patient with cerebral palsy

Ward round/ CBD MCQ

Formulate the treatment plan of cerebral palsy

Ward round/ CBD MCQ


Take a detail history of patient with cerebral palsy

Case discussion Structured Long case

Perform clinical examination of patient with cerebral palsy


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MURMURS Knowledge


Differentiate between cyanotic and

acyanotic congenital heart diseases on

the basis of clinical features

Ward round/ CBD/ OMP MCQ

Interpret the results of basic investigations (CXR) required to diagnose congenital heart disease

Ward round/ CBD MCQ

Devise treatment plan of cyanotic congenital heart disease depending upon underlying cause

Ward round/ CBD MCQ

Discuss the valvular involvement in rheumatic heart disease

Ward round/ CBD MCQ

Interpret the results of basic investigations (CXR, ESR, CRP) of rheumatic heart disease

Ward round/ CBD MCQ

Formulate treatment plan of rheumatic heart disease depending upon underlying cause.

Ward round/ CBD MCQ


Take a detail history of a patient having heart disease

Case discussion Structured Long case

Perform a clinical examination (cardio vascular system examination) of a patient having murmur.


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ANEMIA/PALLOR Knowledge


Differentiate among the diseases causing anemia at various ages on the basis of clinical features (iron deficiency anemia, Vitamin B12 and folic acid anemia, thalassemia major)

CBD/ walk round MCQ

Interpret the results of investigations in a pediatric patient with anemia

CBD/ walk round MCQ

Devise a plan of management for a patient of anemia according to the underlying cause (iron deficiency anemia, Vitamin B12 and folic acid deficiency anemia)

CBD/ walk round MCQ

Discuss the clinical features, pathophysiology and complications, investigations and treatment plan of thalassemia

CBD/ walk round MCQ


Take an age appropriate history in an anemic pediatric

patient (nutritional anemia/ thalassemia)

Case discussion Structured Long

case

Perform appropriate physical examination of an anemic

patient (nutritional anemia/ thalassemia)

Clinical

examination

OSCE


Counsel a patient of thalassemia Role play OSCE

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BRUISING/PETECHIEA Knowledge


Discuss differential diagnosis of bleeding in a pediatric

patient according to clinical features (ITP, hemophilia, , henochschonleinpurpura, leukemia)

CBD/ walk round MCQ

Interpret the results of investigations of a patient with petechiea and bruises.

CBD/ / walk round MCQ

Devise a management plan in a pediatric patient with

bruises/ petechiea according to underlying cause

CBD/ / walk round MCQ


Take an age appropriate history of a patient with bruising/petechiea

Case presentation Structured Long

case

Perform an appropriate physical examination in patient with bleeding

clinical

examination

OSCE

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OEDEMA Knowledge


Differentiate among the causes of generalized oedema in children on the basis of clinical features.

CBD/ward rounds MCQ

Interpret the investigations of a patient with oedema

(nephrotic syndrome , AGN)

CBD/ward rounds MCQ

Devise a management plan in a patient with oedema

(nephrotic syndrome , AGN)

CBD/ward rounds MCQ

Discuss complications in patient with nephrotic syndrome / AGN

CBD/ward rounds MCQ


Take an appropriate history in a patient with oedema

Case discussion Structured Long

case

Perform an appropriate clinical examination of a child with oedema

Clinical

examination

OSCE

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ENDOCRINE PROBLEMS


Differentiate between the clinical features of hypothyroidism

Ward round/ CBD MCQ

Interpret the investigations required for diagnosis of hypothyroidism

Ward round/ CBD MCQ

Outline management plan in pediatric patient with hypothyroidism

Ward round/ CBD MCQ


Take an age appropriate history of a patient with hypothyroidism

Case presentation Structured Long case

Perform examination of a pediatric patient with hypothyroidism

Clinical methods OSCE

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DAILY TIME TABLE

Day 8-9:30 9:30-10:30 11-1:00 1-2

Monday Clinical methods

Walk round CBD/TBL/CP Role play

Tuesday Clinical Method Walk round CBD/TBL/CP Interactive tutorial/OM P X 3

Wednesday Clinical methods

Walk round CBD/TBL/CP Role play

Thursday Clinical methods

Walk round OMP X 3 (OPD)

CBD/TBL/C P

Friday Clinical methods

Walk round CBD/TBL/CP -------

Saturday Clinical methods

Walk round CBD/TBL/CP OMP X 3(ER)

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Monday Tuesday Wednesday Thursday Friday Saturday

Week 1 growth &

development

Preventive

pediatrics

Neonatology Fever Genetics

Week 2 Diarrhea Cough Bruising/ petechiea

Seizures Mental retardation

Jaundice

Week 3 Rash Murmurs Anemia Oedema Endocrine disorders

assessment

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CHECKLISTS FOR CLINICAL METHODS

CLINICAL METHODS CHECK LISTS

MALNUTRITION

Take consent

Perform anthropometric measurements

Examine for macronutrient and micronutrient deficiencies

Examine for signs of dehydration

EXAMINATION OF NEWBORN

Take consent

Wash hands

Examine for color, cry, activity and vital signs

Examine for congenital anamolies

Perform neonatal reflexes

NEONATAL RESUSCITATION

Prepare to receive the baby

Check instruments

Perform steps of neonatal resuscitation

Document the procedure and baby‟s condition

ANTHROPOMETRY

Take consent

Takeheight, weight and OFC accurately

Plot the data on age appropriate charts

Interpret the findings

GIT

Take consent

Inspect abdomen

Palpate for tenderness and masses

Palpate and percuss the liver

Palpate and percuss the spleen

Palpate kidneys

Perform shifting dullness and fluid thrill

Examine hernia orifices

Examine back

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RESPIRATORY SYSTEM

Take consent

Listen for abnormal sounds (stridor, wheeze)

Examine for cyanosis, chest deformities, chest indrawings

Percuss chest anteriorly, posteriorly and laterally

Auscultate chest anteriorly, posteriorly and laterally

Perform vocal resonance

CVS

Take consent

Examine for central and peripheral cyanosis, clubbing,oral hygiene, JVP, oedema.

Examine pulses

Check blood pressure with appropriate sized cuff

Examine shape of precordium and pulsation

Palpate for pulsations and thrills

Auscultate precordium for heart sounds and murmurs

Examine liver and spleen

Examine for signs of infective endocarditis

CNS

Take consent

Check GCS accurately in infants and older children

Examine higher mental functions

Examine cranial nerves

Examine gait

Examine the motor system

Examine the sensory system

Examine for cerebellar signs

BRUISES/PETECHIEA

Take consent

Examine for pallor, bruises, petechiea on skin

Examine oral cavity for petechiea

Examine all lymph nodes


Examine joints for swelling and tenderness

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PALLOR/ANEMIA

Take consent

Examine nails and conjunctiva for pallor and anemia

Examine lymph nodes


Examine for bruises and petechiae

Examine for other micronutrient deficiency.

SIGNS OF DEHYDRATION

Take consent

Look for conscious level

Look for sunken eyes

Look for tears in eyes

Feel for skin turgor

Palpate peripheral pulses

RASH

Take consent

Inspect for general condition

Evaluate GCS

Examine for SOMI

Check vital signs

Examine conjunctiva

Examine for stomatitis

Examine the skin for rash (palpate and look for blanching)

Examine lymph nodes

Auscultate chest

Examine for signs of dehydration

DOWN‟S SYNDROME

Take consent

Inspect general condition

Examine for dysmorphic features of Down‟s syndrome

Take anthropometric measurements

Examine for hypotonia

Examine heart for murmurs

Examine abdomen for distension

Examine anal opening

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OEDEMA

Take consent

Take vital signs (pulse, B.P. R/R, temperature)

Examine for extent of oedema (ankles, ascites, pleural effusion, facial puffiness)

Examine for signs of heart failure

Examine for jaundice and bleeding

Examine liver, spleen and kidneys

FEVER

Take consent

Take vitals

Examine for rash

Examine ear and throat, conjunctivitis and stomatitis.

Examine for koplick spots

Examine lymph nodes

Examine for hepatosplenomegaly

Examine joints

JAUNDICE

Take consent

Examine general condition

Examine conscious level

Look for jaundice, pallor. Clubbing, asterixis palmar erythema, spider neavi, oedema

Examine abdomen for prominent veins/ caput medusae

Examine for hepatosplenomegaly

Examine for ascites

HYPOTHYROIDISM

Take consent

Examine for dysmorphic features

Examine neck for goiter

Examine the skin for dryness and temperature

Examine for hypotonia

Examine for poor suck

Examine knee jerk

Take anthropometric measurements

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CHECKLIST FOR COUNSELLING SKILLS TOPICS CHECK LISTS

BRONCHIAL ASTHMA

Introduction/ putting patient at ease

Demonstrate Active listening

Avoid technical language

Invite open ended questions

Demonstrate empathy

History (symptoms of cough and breathlessness, family history of asthma, atopy)

Ask about risk factors

Explain about various options for treatment

Explain use of metered dose inhalers

Emphasize on practicing preventive measures

Summarize

THALASSEMIA





Demonstrate empathy

Discuss History and examination findings

Discuss relevance of investigations

Discuss treatment options and prognosis

Genetic counseling

Screening of siblings/ other family members

Prenatal diagnosis

Summarize

DOWN‟S SYNDROME





Demonstrate empathy

Explain the cause of Down‟s syndrome and correlation of maternal age

Discuss the results of investigations

Explain about

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o Discuss management options

o Discuss prognosis

o Summarize

FEVER





Demonstrate empathy

History (duration, associated symptoms)

Discuss investigations

Discuss treatment options

DIARRHOEA





Demonstrate empathy

History (duration, frequency, characteristics of stool, vomiting, fever,state of dehydration)

Discuss investigations required

Discuss treatment plan

JAUNDICE





Demonstrate empathy

History

Discuss investigations required

Discuss treatment plan

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REFERENCE BOOKS

Illustrated textbook of Pediatrics by Tom Lissauer and Graham Clayden

Basis of Pediatrics by Pervaiz Akbar 7th Edition

Text Book of Pediatrics , PPA, 3rd Edition

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Pediatric Clerkship Module

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