Download Endocrinology - University of Illinois College of Medicine at Peoria

Pediatric Endocrinology Subspecialty Rotation
University of Illinois College of Medicine at Peoria
Children’s Hospital of Illinois / OSF Saint Francis Medical Center
Clinic Schedules
The week prior to rotating, get ENDO call schedule from Teresa Poshard
([email protected]). Arrive at the clinic 30 minutes prior to review patient’s charts for
the day. The charts are located in the patient registration desk area.
Faculty
Sue Sauder
Joyce Wise
Alex Aguilar
Roxana Aguirre
Valeria Benavides
Brian Bostwick
Clinics
Hillcrest Medical Plaza*
Ped Subspecialty Clinics
Suite 401
420 NE Glen Oak
Peoria, IL 61603
(309) 624-9844
Gerlach Building
Pediatric Diabetes Resource Cntr **
Suite 1141
530 NE Glen Oak
Peoria IL 61603
(309)624-2480
General Clinic Days and Hours
Monday
Tuesday
Wednesday
Thursday
Friday
AM
Dr. Wise*
Dr. Aguilar*
Dr. Benavides**
Dr. Bostwick**
Dr. Wise**
Dr. Aguilar*
Dr. Aguirre**
Dr. Benavides*
Dr. Sauder**
Dr. Aguilar**
Dr. Aguirre*
Dr. Benavides**
9:00-10:00
Grand Rounds
Dr. Sauder**
Dr. Sauder*
Dr. Bostwick**
PM
Dr. Aguilar *
Dr. Aguilar *
Dr. Benavides*
Dr. Aguirre*
Dr. Aguirre*
Clinic schedules are subject to change. Please ask Teresa Poshard for the monthly schedule.
Hormone stimulation testing is performed at the Hillcrest office on Thursday mornings from 8 –
12 AM.
Diabetes education sessions are held at the Diabetes Resource Center during business hours
from 8 AM to 4 PM.
Rotation Goals and Objectives
*Competency Domains:
PC = Patient Care
MK = Medical knowledge
PBL = Problem Based Learning & Improvement
ISC = Interpersonal skills & Communication
PRO = Professionalism
SBP = System Based Practice
1. To familiarize the resident with endocrine disorders and their management in both the
outpatient clinics and inpatient services. *PC/MK.
2. To instruct the resident on the practical aspects of diabetes mellitus management.
*PC/MK.
3. To develop a system for investigating selected topics in depth using the current
literature. *PBLI.
Activities
1. Attend all available outpatient clinics at the Hillcrest Medical Plaza and Pediatric
Diabetes Resource Center (Easter Seals). Residents are encouraged to review charts
before coming to clinic. At the Attending Physician’s discretion, the resident will be the
person of first contact with the patient and their families and then discuss any findings
with the attending and diabetes team. The resident will coordinate the patient’s care with
team members and understand team role members. Residents are responsible for a
complete note (including differential diagnosis and plan) on each patient seen.
*PC/MK/ISC/SBP.
2. Manage the inpatient service with supervision. The resident will be the person of first
contact and responsible for the consult notes and daily progress notes on all endocrine
service patients. The resident should formulate a differential diagnosis and plan prior to
discussing the patient with the attending and completing the consultation note. The
resident will be responsible for reading about the endocrine patient’s disease and
serving as the “expert” and advisor for general pediatric service residents. The resident
will do any necessary discharge dictations. *PC/MK/ISC.
3. Participate actively in tutorials and case discussions. The resident will be encouraged to
research in the current literature and discuss with an attending how the data applies to
our patients. *PC/MK/PBLI.
4. Independent Study
a. Endocrine curriculum including the 8 basic areas: growth, puberty, thyroid,
parathyroid, adrenal, calcium and phosphorus, sex differentiation disorders, and
diabetes mellitus type 1 and type 2.
b. You will need to choose a topic of your choice for in-depth review and
presentation during the rotation. It should be narrow enough to include
information at the molecular level as relevant. This needs to be chosen and
approved within the first week and will be presented the last week of the rotation.
You can use PowerPoint or notes; however, you will be expected to understand
the core concepts and be able to answer questions. A list of references used for
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preparation and a copy of your outline need to be submitted for discussion.
Please avoid “reading” your presentation. Visual aids or notes should be used to
guide your topic’s discussion. *MK/ICS/PRO/PBLI
Endocrine Core Curriculum: PC/MK/PBLI
Primary Goal:
Understand the role of the pediatrician in prevention, screening and counseling patients and
their families with endocrine disorders.
Specific Goals
I.
GROWTH
Goal: Differentiate between normal, physiologic deviations from normal and
pathologic findings related to endocrinology
A. Short stature
 Distinguish among constitutional short stature, genetic short stature,
growth hormone failure and idiopathic short stature by growth chart evaluation
 Normal variations of growth including familial short stature and constitutional
growth delay
 Identify proportionate and disproportionate short stature (achondroplasia,
hypocondroplasia)
 Recognize the signs and symptoms of acquired and congenital growth hormone
deficiency
 Know the various causes of growth hormone deficiency (idiopathic growth
hormone deficiency, growth hormone resistant syndrome, IGF-1 deficiency)
 Recognize endocrine dysfunction that affects linear growth such as growth
hormone deficiency, hypothyroidism, Cushing’s syndrome, etc.
B. Tall stature
 Differentiate among the causes of tall stature (i.e. familial, Klinefelter syndrome,
acromegaly, Marfan syndrome).
II.
PUBERTY
Goal: Recognize the stages of sexual development (sexual maturation rate) using
the Tanner staging method among boys and girls
A. Normal
 Recognize the stages of sexual development
 Know the range of age of the onset of puberty among boys and girls in
the U.S.
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 Know that peak height velocity in girls occurs earlier in Tanner staging
(and chronologically) than in boys
 Recognize the methods for assessing the relationship of parental stature
to individual adolescent’s stature
 Know that Tanner staging in girls (breast and pubic hair) is usually
parallel, whereas genital staging usually precedes pubic hair a staging in boys
 Know that testicular enlargement is the earliest sign of puberty in boys
 Understand that an individual adolescent’s bone age and chronological
age may disparate by as much as two years and still be within normal limits
 Know there is a genetic influence on the timing of puberty (including
age at menarche)
 Know that pubertal progression from sexual maturity rating from Tanner
stage 2 to 5 can require 2.5 years to complete
 Understand the impact of relatively early or late puberty on final adult
height
 Know that most boys achieve a genital sexual maturity rating (Tanner)
of stage 4 prior to the attainment of peak height velocity
 Know the sequence of development of secondary sexual characteristics
in boys (testicular growth, pubarche, penile growth, peak height velocity)
 Know that a testicle of less than 3 ml in diameter or less than 2.5 cm in length
is prepubertal
 Distinguish between the variations of normal (thelarche, pubarche) and
precocious puberty
 Know the physiopathology and management of normal vs. abnormal
gynecomastia in males
 Recognize that pubertal gynecomastia as well as breast development can be
asymmetric and that neither indicates pathology
 Understand the significance of a breast mass in an adolescent girl
 Know the sequence of development of secondary sexual characteristics in girls
(breast budding, pubarche, peak height velocity, menarche)
 Know that girl’s height will rarely increase more than 2 inches after menarche
has occurred
 Know that vaginal bleeding in a girl with a sexual maturity rating (Tanner) at
stage 2 for breast development is not likely to represent menarche (menarche
usually occurs in stage 4)
 Know that infrequent menstrual periods within the first 2 years after menarche
do not warrant laboratory investigation under most circumstances
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 Know the preferred treatment of dysfunctional uterine bleeding in adolescence
and that surgical intervention is rarely necessary
 Know the etiologies of secondary amenorrhea and their respective treatments
 Know the characteristics of adolescents with PCOS
 Know that the adolescent peak height velocity is more closely correlated with
sexual maturity rating stage than with chronological age
 Know the average prepubertal height velocity (5-6 cm/year) and the
accelerated rate (9-10 cm/year) in the peak adolescent growth spurt and that
completion of the pubertal growth spurt takes 2-4 years
 Know that the absence of any sign of puberty after the age of about 13 years in
a girl or about 14 years in a boy merits investigation
 Know that most delayed puberty in boys is constitutional
 Know that Turner syndrome can present for the first time as pubertal delay
 Understand the limitations of knowing height and weight at only one point in
time in assessing a short adolescent (growth velocity is more important that a
single measurement)
 Know that hormones that accelerate the rate of growth also accelerate closure
and have the ultimate effect of limiting growth potential
 Know that premature arrest of previously normal growth rate in adolescent
demands thorough endocrinologic/neurologic evaluation
 Know the psychological risk for boys and girls with delayed puberty
B. Precocious puberty
 Recognize true precocious puberty versus premature adrenarche
 Recognize the tumors that may produce precocious puberty (i.e. idiopathic,
hamartomas, craniopharyngioma, granulosa or theca cell tumors)
C. Delayed
 Recognize the signs and symptoms of delayed puberty due to CNS etiology
 Recognize the signs and symptoms of gonadal dysgenesis
 Know the laboratory evaluation of gonadal dysgenesis, including karyotype and
serum concentrations of LH, FSH, androgens and estrogens
 Understand the importance of cardiac and renal disorders in Turner syndrome
 Understand the familial influences of the onset of puberty
 Recognize the signs and symptoms of constitutional delayed puberty
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 Know how to use data collection to diagnose and distinguish between
constitutional delayed puberty and other conditions
III.
THYROID DISORDERS
Goal: Understand the general pediatrician’s role in the diagnosis and management of
thyroid dysfunction in patients with congenital and acquired hypothyroidism,
autoimmunity, hyperthyroidism, thyroid masses and tumor
A. Hashimoto’s thyroiditis (Chronic autoimmune thyroiditis)
 Recognize the signs and symptoms of Hashimoto thyroiditis
 Know the laboratory studies that distinguish among Hashimoto thyroiditis, other
causes of thyroid enlargement and hypothyroidism
 Know the natural history of Hashimoto thyroiditis
 Know how to treat Hashimoto thyroiditis
 Know that Hashimoto thyroiditis is the most common cause of goiter in
adolescents with a female to male ratio 3-4:1
 Know that Hashimoto thyroiditis may be associated with other autoimmune
disorders
B.
Cyst, tumor
 Recognize the signs and symptoms of a thyroid cyst/tumor
 Know how to use laboratory evaluation in a child with a thyroid mass
 Know the significance of a previous history of irradiation to the head and neck
in a patient with a thyroid cyst/tumor
 Know that a solitary thyroid nodule may be a sign of thyroid cancer
C.
Hypothyroidism
 Know the consequences of untreated hypothyroidism in the neonate
 Recognize the signs and symptoms of hypothyroidism
 Know how to use laboratory tests effectively to diagnose hypothyroidism
 Know the varying causes of hypothyroidism
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 Know how to manage and treat hypothyroidism and the use of TSH to guide
the treatment
 Know the prognosis for a patient with hypothyroidism
 Know how to recognize thyroid-binding globulin deficiency
D.
Hyperthyroidism
 Be aware of various treatment modalities for hyperthyroidism and
complications of treatment
 Recognize the signs and symptoms of a thyroid storm and treatment
 Recognize the signs and symptoms of neonatal hyperthyroidism
IV.
PARATHYROID DISORDERS
Goal: Understand the role of parathyroid hormone in calcium, phosphorus and
skeletal homeostasis
 Recognize the typical laboratory findings associated with hypoparathyroidism
 Know how to recognize a child with pseudohypoparathyroidism
 Know that DiGeorge syndrome (22q-) can be a cause of hypoparathyroidism
 Know that hyperparathyroidism is common in patients with chronic renal
insufficiency
 Identify the most common laboratory findings in parathyroid dysfunction
V.
ADRENAL GLAND DISORDERS (I.E. ADDISON DISEASE)
Goal: Identify patients with cortisol deficiency and management of adrenal crisis
 Recognize the signs and symptoms of Addison disease
 Know how to use laboratory tests effectively for the diagnosis of Addison disease
 Plan the treatment of an adrenal crisis in a patient with Addison disease
 Know the causes of Addison disease and related disorders
 Recognize that Addison disease is an autoimmune disorder
 Be aware of adrenoleukodystrophy
 Congenital adrenal hyperplasia (see section of disorders of sexual
differentiation/ambiguous genitalia)
VI.
TYPE 1 DIABETES MELLITUS
Goal: Identification, diagnosis and treatment of uncomplicated and complicated type
1 and type 2 Diabetes Mellitus
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A. General
 Recognize the signs and symptoms of type 1 diabetes
 Know how to treat type 1 diabetes effectively to achieve good control: insulin, diet,
exercise
 Know how to treat type 1 diabetes effectively to achieve good control: insulin, diet,
exercise and psychological acceptance of the disease
 Know the value of hemoglobin A1c in the management of type 1 diabetes
 Know the natural history of type 1 diabetes
 Counsel patients on the self-management of type 1 diabetes
 Differentiate between the Somogyi and Dawn phenomena
 Know how to manage sick days in diabetic patients
 Know the long term complications of type 1 diabetes
 Know the importance of blood glucose control in the prevention of long-term
complications of type 1 diabetes
 Recognize the association between type 1 diabetes and other autoimmune
disorders
 Know the treatment modalities used in type 1 diabetes (i.e. subcutaneous
injections, insulin pumps, glucose sensors)
B. Diabetes Ketoacidosis (DKA)
 Know the complications of type 1 diabetes, particularly DKA and its
pathophysiology, treatment and complications (hypokalemia, hypoglycemia,
cerebral edema, shock)
 Recognize cerebral edema as a complication of the treatment of diabetic
ketoacidosis
 Understand the risks of using bicarbonate in diabetic ketoacidosis
 Understand how noncompliance plays a role in recurrent DKA
VII.
TYPE 2 DIABETES (NONINSULIN-DEPENDENT DIABETES MELLITUS)
 Understand the difference between type 1 diabetes and type 2 diabetes
 Know that acanthosis nigricans is a marker for insulin resistance
 Understand the treatment approaches to type 2 diabetes
 Understand that etiology of obesity is multifactorial
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 Know the genetic conditions that are responsible for obesity in children
 Know that nutritional support, behavior modification and exercise are essential
components in the treatment plan for obesity
 Know the etiology of hypoglycemia during the newborn period
VIII.
DISORDERS OF CALCIUM AND PHOSPHATE METABOLISM
Goal: Identify the most common causes of calcium and phosphate metabolism at
different age groups, signs, symptoms, laboratory work-up and appropriate treatment
A. Hypocalcemia
 Recognize the signs and symptoms of hypocalcemia
 Know the causes of hypocalcemia in a neonate
 Know the hypocalcemia with hypophosphatemia suggests vitamin D deficiency
 Know that hypocalcemia with hyperphosphatemia suggests hypoparathyroidism
B. Hypercalcemia
 Recognize the signs and symptoms of hypercalcemia
 Recognize the possibility of hypercalcemia and its complications following
prolonged immobilization
C. Hypophosphatemia
 Recognize the typical clinical and laboratory findings associated with familial
hypophosphatemic rickets
 Plan the treatment of a child with familial hypophosphatemic rickets
IX.
SEX DIFFERENTIANTION
Goal: Understand the role of the pediatrician in recognizing normal vs. abnormal
anatomy of the external genitalia, identification of most common causes of ambiguity,
diagnosis, genetic and/or molecular basis and treatment.
A. Normal development
 Know the normal anatomy of the genitalia and its development
 Understand the effect of androgens on the formation of the external genitalia
 Understand the effect of müllerian-inhibiting factor on the internal duct structure
B. Ambiguous genitalia
 Recognize the signs and symptoms of congenital adrenal hyperplasia
(CAH)
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 Know the laboratory evaluation of CAH
 Know that CAH can be diagnosed prenatally
 Plan the treatment for an adrenal crisis in a patient with CAH
 Understand the value of neonatal screening for salt-losing CAH in male infants
 Recognize the signs and symptoms of male pseudohermaphroditism (46, XY with
testes)
 Understand that maternal exposure to androgens or progestins can cause
virilization in female infants
X.
HEALTH MAINTENANCE AND PREVENTION IN ENDOCRINOLOGY
The role of the pediatrician in identifying individuals at risk for the development of
endocrine dysfunction.
 Know how to interpret the newborn screen (example, congenital hypothyroidism,
congenital adrenal hyperplasia, galactosemia)
 Early identification of growth acceleration or deceleration as seen in growth
hormone deficiency or acromegaly
 Know the importance of vitamin D supplements in breast-fed infants and select
populations with low intake of vitamin D, calcium or phosphorus
 Diabetic screening for patients with polyuria, polydipsia, polyphagia, recent and
unexplained weight loss, acanthosis nigricans
 Obese children should be screened for dysmetabolic syndrome (obesity, insulin
resistance, diabetes, hypertension, lipid dysfunction)
 Understand that treatment for obesity includes an appropriate nutrition, behavioral
modification and exercise
 The association of chronic steroid use and decreased bone mineral density
 The common symptoms associated with the abuse of anabolic steroids
 The need for influenza vaccination in children with certain endocrine disorders
(CAH, diabetes mellitus, hypopituitarism, Cushing syndrome)
 The importance of diabetes control for prevention of long-term complications such
as retinopathy, neuropathy, nephropathy, vascular insufficiency and gastroparesis
XI.
DIAGNOSTIC AND SCREENING PROCEDURES
Goal: The role of the pediatrician using tools to identify endocrine dysfunction,
interpretation and referral to endocrinologist if necessary
 Proper use of growth, length, weight and BMI charts
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 Use of orchidometer in the assessment of sexual development
 Use of staidiometer for accurate height measurement
 Interpretation of bone age and DXA scans
Resources:
Kittredge, D., Baldwin, C. D., Bar-on, M. E., Beach, P. S., Trimm, R. F. (Eds.). (2004). APA
Educational Guidelines for Pediatric Residency. Ambulatory Pediatric Association Website.
Available online: www.ambpeds.org/egweb.
th
th
Essentials of Pediatrics, 5 edition. Nelson Textbook of Pediatrics, 18 edition. Nelson
PREP: self-assessment Q&A from Pediatrics Review and Education Program, section
Endocrinology and Metabolism.
General Pediatrics Outline Contents/Certifying Examination. Available online:
www.abp.org/certinfo/genpeds/gpoutline.pdf
rd
Textbook of Pediatric Endocrinology, Sperling 3 edition. Textbook of Pediatric
th
Endocrinology, Lifshitz, 4 edition
Revised 4/8/11
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