Genesys FP Residents - Resident Site

Course of Training Your schedule of clinical rotations is designed to meet Accreditation Council on Graduate Medical Education and American Osteopathic Association requirements for internship and family practice. Your residency training also includes regular conference presentations, grand rounds and seminars. Osteopathic principles and practices are emphasized throughout the residency for our osteopathic family practice residents.

As a second and third year resident, you can expect a more demanding schedule, as you become more involved in ambulatory patient care. Procedural skills and providing empathetic patient and family oriented care are hallmarks of our program. Throughout your three yeas, your progress is closely monitored and you receive regular feedback. The following clinical rotations and objectives are included in our training curriculum.

Internal Medicine As a first year resident, your primary responsibility is to learn the basic principles associated with internal medicine and to provide the medical attention your patients need. During the second year of your residency, you continue to manage your own patients, as well as those with more complicated illnesses, including intensive care and step down unit cases. Throughout your three years, our responsibilities increase in patient care and in the teaching and supervision of junior resident cases.

Obstetrics/Gynecology Many family physicians have chosen to include obstetrics and gynecology in their practices. For those residents who elect to do an OB track we have designed our program to meet those demands with intensive, rigorous training. Throughout your residency training, you are responsible for a large number of patients, including routine and at risk pregnancies. This clinical rotation allows you to perform vaginal deliveries and assist in cesarean sections. You learn to recognize which patients require assistance from an obstetrician and you are trained in a variety of other areas including nutrition, breast-feeding and preparation for parenting. Our requirements in this area are more rigorous than the usual family practice residency.

Pediatrics There is an emphasis on pediatrics in the Family Health Center. Throughout your residency, you handle a variety of illnesses both on an inpatient and outpatient basis. You will attend conferences and participate in a variety of specialty clinics including Cardiology, Neurology, Gastroenterology, Pulmonology and Endocrinology. These clinics are staffed with highly qualified pediatric sub-specialist from the University of Michigan-Ann Arbor.

Surgery Throughout your residency, you are trained in a variety of surgical procedures, many of which can be performed in your office on an outpatient basis. Since you are the first physician many of your patients will see, competency in this area is extremely important. You are expected to provide the initial diagnosis and often the initial care for emergency surgical problems. Your surgery rotation gives you a strong background in diagnosis, outpatient and emergency surgery. Emphasis is also placed on post-operative care.

Behavioral Science Your behavioral science curriculum serves as an integral part of your residency training. Health and illnesses are approached from a biopsychosocial perspective. The Family Health Center is the primary learning site for your training. During your first year, you will gain experience in training and experience in the medical interview. As a first and second year resident, you will also complete a behavioral science rotation.  In the third year you will have additional behavioral science training in your ambulatory care rotation. The doctor/patient relationship, family relationships and social issues affecting health are among the topics covered. Throughout all three years, the family practice faculty will work with you in one-to-one precepting and videotaped precepting. These activities are designed to help you enhance your communication and examination skills. Genesys maintains a post-doctoral fellowship in Primary Care Health Psychology that trains clinical and counseling psychologists. Through a consortium arrangement, this program is accredited by the American Psychological Association. This rich learning environment allows for psychologist faculty members and psychology fellows to be available to assist residents in their learning.

Geriatrics As part of your geriatric training, your studies include important topics such as Alzheimer’s disease and other dementia, depression, cardiac and renal diseases, as well as various lectures on related health issues. You also conduct home visits with or Case Management Team. Your course of training includes inpatient and outpatient evaluation and management of elderly patients covering a wide array of illnesses. The ability to provide primary care and consultation for the older adult in acute, ambulatory and community long-term care situations is an important part of your training.

Orthopedics Disorders of the musculoskeletal system are common and family practice physicians require special training in this area. You learn to diagnose and treat patients with common orthopedic disorders through a rotation that includes training in the orthopedist’s office, clinics, emergency room and operating room. The rotation provides training in reading radiographs and accurately describing all types of fractures along with the ability to stabilize fractures (casting, wrapping). You learn proper diagnosis and treatment of orthopedic problems such as congenital hip dislocation and Legg-Calve-Perthes disease along with common musculoskeletal disorders such as back pain and sports injuries.

ENT The course of training in the ENT rotation includes the ability to accurately diagnose and initiate treatment for common ENT disorders including otitis media, vertigo, tinnitus, sinusitis, laryngitis and tonsillitis. Good patient communication skills are stressed as you learn to discuss various health concerns such as hearing aids, myringotomy tubes, treatment options for tonsillitis and others. Along with basic office procedures such as laryngoscopy, you learn the ability to recognize when to refer first line treatment failures to specialists for possible surgery.

Ophthalmology Ophthalmology training includes diagnosis and treatment of external eye problems such as strabismus, disorders of the eyelid, conjunctivitis, corneal abrasions and trauma. Disease of the inner eye including glaucoma, cataracts and retinal changes associated with metabolic disorders such as hypertension and diabetes, are part of the training. Procedures essential to providing quality ophthalmologic care include thorough fundiscopic exams, proper use of a slit lamp and removal of foreign objects from the eye.

Dermatology Office dermatologic procedures such as bacterial and fungal cultures, skin biopsies and removal of moles and warts along with the diagnosis, treatment and required healing time for most common primary skin disorders are part of your course training in dermatology. Ongoing lecture series as well as office rotation gives you the basis for diagnosing and managing acne, eczema, psoriasis and other common skin conditions.

Emergency Medicine Family Practice physicians often provide the initial and acute care for a variety of injuries and medical conditions. Over the course of your residency training, you will be exposed to a variety of emergencies and acute care training settings including pediatric ER, with increasing responsibility for the management of acute care patients.

Faculty Advisor

The Faculty advisor program is designed to provide residents with an advisor, who can act as a mentor, helps residents develop learning goals and be someone with whom they can share their concerns.

Roles:

Resident:

Faculty Advisor:

1. Meets with new resident for first interview during orientation


2. Is prepared to discuss individual advisees at Quarterly Faculty Meeting


3. Clarifies goals, expectations, shares resources as appropriate


4. Assists resident to compare rotation evaluations to self-evaluation


5. Reviews rotation evaluations, Basic Clinical Skills Assessment, H & P evaluations, "special" evaluations, FHC evaluations and others as indicated


6. Adds perspective to resident’s self-evaluation of FHC responsibilities


7. Counsels residents if needed

Time off, Vacation, Sick Day and Conference Policy

Please refer to the Medical Education policy and procedures for paid time off (PTO) for details of this policy. Listed below are a summary of these policies with specific guidelines for Family Practice residents

Paid Time Off

As per resident contracts, the total paid time off listed below includes all vacation, sick and personal days

PGY I             15 working days (Monday – Friday)

PGY II & III   20 working days (Monday – Friday)

• All time off that exceeds this time allowed will need to be made up during the current contract year.

• When vacation or conference days are approved, it is the responsibility of the resident to notify the attending and senior on the respective service or the doctor’s office where the resident will be on rotation

• No vacation or conference days will be carried over to the next year.

POLICY OF LIFE SUPPORT CERTIFICATIONS FOR

FAMILY PRACTICE RESIDENTS

All Interns/Residents of the Family Practice Program must maintain current BLS and ACLS certification during their training at Genesys Regional Medical Center.

The Family Practice Program requires all first year interns/residents to become ALSO Certified and second year residents are also required to obtain certification in the Neonatal Resuscitation Program (NRP) and in Pediatric Advanced Life Support (PALS).

Family Practice Residents who do not comply face suspension and/or non-advancement until certification is obtained.

Any resident who does not re-certify before their certification expiration date will be responsible for the difference of course fees between a Provider Course and a Re-certification Course.

Note: There is no longer a 60-day grace period for re-certification.

Procedure:

It is the responsibility of the resident to:

1. Be certified, maintain current certification and provide the Department of Medical Education with copies of their certification cards. Residents who lose their cards are responsible for the $2.00 replacement fee.

The Department of Medical Education will assist all trainees by:

1. Maintaining a database with expiration dates to remind residents of impending expiration of certification. Posting of dates on the Medical Education Web Page and resident call rooms.

1. Medical Education will post all BLS / ACLS / NRP / PALS and ALSO Provider/Recertification Courses offered at Genesys and those offered at other institutions on the Medical Education Web Page.

RESIDENT EVALUATION POLICY

Since July 1993, resident evaluation is a function of the Curriculum Development and Evaluation Committee, and is a continuous process. The CDE Committee membership consists of full-time Family Practice faculty, Program Directors, and Director of CDE/Medical Education Department. The Curriculum Development and Evaluation Committee (CDE) reviews resident performance monthly and makes recommendations to the Program Director and faculty of the Family Practice Program. These recommendations are presented at the Quarterly Faculty Meetings held in September, January and March/April. All recommendations are subject to the final approval of the Program Director.

CDE will review the following areas of performance:

I. General Attendance and Responsibility:

A. CDE will monitor residents' attendance at required conferences including morning report and CME. Excused Absences include only the following:

1. Sick day phoned in to Family Practice Office 606-5985


2. Away rotation with location a minimum of 50 miles away from GRMC


3. Approved Vacation Time (PTO)


4. Deliveries, CODES, Urgent floor calls – must call Family Practice Office 606-5985


5. Skeleton crew assignment

Failure of a resident to meet minimum standards for conference attendance will result in a jeopardy call during the next block.

B. CDE will review reports of tardiness and unexcused absence from the program.

C. CDE will review reports of failure to comply with hospital policies and procedures including timely completion of medical records.

D. CDE will review reports from faculty, attending staff and other hospital staff regarding inappropriate or unprofessional behavior.

E. Any problem area deemed significant by CDE will result in a recommendation to the program director for corrective action.

II. Evaluations:

A. Resident performance:

CDE will monitor resident performance on all rotations by reviewing rotation specific evaluations submitted to CDE by attending physicians.

Rotation evaluations will be standardized by CDE to a scale of 1 (= FAIL) to 5 (=outstanding) with a mean of 3 to 4. CDE may assign numerical values to written comments when appropriate. In addition, the faculty will evaluate residents on the ACGME/AOA core competencies.

B. CDE will recommend corrective action if a resident receives less than satisfactory evaluations.

C. CDE will monitor the performance of teaching faculty and the goals and objectives for each rotation. This feedback is received from residents completing a rotation evaluation form at the end of each rotation. When indicated, CDE will make changes in the rotation. Issues involving faculty will be reviewed by the CDE Committee, recommendations made to the program directors that will meet with the attending physician.

D. Rotation Quizzes:

CDE will implement rotation quizzes utilizing the AAFP Monograph Series to assess mastery of assigned readings.

Failure to submit the Rotation Quiz and Rotation Evaluation by the last Friday of the Block Rotation will result in an immediate Jeopardy Call.

Completion of all Block Rotation Quizzes is a requirement for promotion or graduation.

E. Quarterly Exams:

CDE will implement Quarterly Exams utilizing the ABFP Monograph Series and previous ABFP In-Training Exams. These will occur in:

July Ob-Gyn Monograph Assignments

September ABFP In-Training Exams from previous years.

January Critical Care Monograph Assignments

April Miscellaneous Monograph Assignments

Quarterly Exam Attendance: All Family Practice Residents will attend the Quarterly Exam from7:00 am to 8:00 am in the Resource Lab. This exam will be given on the last Friday of the block in which the Quarterly Exam is scheduled.

Excused absences include only the following:

1. Sick Day phoned to Family Practice Office 606-5985.


2. Away Rotation with location a minimum of 50 miles away from GRMC


3. Approved Vacation time with a scheduled make-up date with CDE Coordinator (606-5991).

Residents will be given a minimum of 30 days notice prior to the date of quarterly exam.

Failure to complete the Quarterly Exam will result in an immediate Jeopardy Call for each working day late.

Completion of all Quarterly Exams is a requirement for promotion or graduation.

F. In-Patient and Ambulatory Site Evaluations:

CDE will monitor evaluations of ambulatory and inpatient care of Family Health Center patients by preceptors. Such evaluations may be generated at random by preceptors, as well as in a manner prescribed by CDE. CDE will recommend corrective action if a resident receives a rating of 1 (FAIL) in any evaluation area.

CDE will recommend corrective action if a resident consistently receives standardized ratings less than satisfactory.

G. Family Practice Faculty Evaluations:

All Family Practice Faculty will evaluate residents on a biannual basis. Evaluations will be a summation of interactions in the FHC, hospital rounds, nursery, L&D. In addition, the faculty will evaluate the residents on the ACGME/AOA core competencies. CDE will recommend corrective action if a resident receives a rating of 1 (FAIL) in any evaluation area. CDE will recommend corrective action if a resident consistently receives standardized ratings less than satisfactory.

H. Research Projects:

CDE will monitor the completion of Research Projects, Presentation at Community Forum and submission of the completed paper. Please refer to Senior Research Project Policy.

I. OMT

All Osteopathic Interns must perform osteopathic manipulation therapy on two (2) in-house patients with COPD. CDE will monitor the completion of the treatments

J. History and Physical Review

History and Physical (H&P) reports dictated by Family Practice residents will be regularly reviewed by Family Practice faculty to ensure high quality of care provided, completeness of medical record and adherence to established H&P format. Please see Review of History and Physical Reports Policy.

III. Periodic Case Evaluations: (BCS I)

CDE will develop and implement a series of case evaluations involving real and simulated patients and apply them as needed so as to assure that residents performing at a given level of training have the necessary clinical skills to perform appropriately. CDE will set pass levels for these evaluations and recommend corrective action if a resident fails any evaluation.

IV. Remediation:

CDE will recommend to the Program Director(s) a plan of remediation when a resident’s performance so indicates. 

V. Annual In-Training Examination:

CDE will monitor residents' performance on the annual In-Training Examination given by the American Board of Family Practice. CDE will recommend corrective action if a resident's total score on the examination is more than 1.5 standard deviations less than the national average.

VI. Credentialing of Procedures: (Administrative Manual)

CDE will monitor the completion by each resident of procedures detailed in the

Department of Medical Education’s Procedure Credentialing Policy. (Administrative Manual) Residents are provided with the necessary handbooks to document and have appropriate signoff by Program Directors of these procedures.

VII. Log Compliance: (Administrative Manual)

CDE will monitor the resident’s completion of their end of rotation logs that include procedures and diagnostic cases.

VIII. Quarterly Faculty Meetings:

CDE will monitor the proceedings of the Quarterly Faculty Meetings. Additional problems with the performance of any resident may be brought to the attention of CDE at the Quarterly meeting. CDE will investigate any such problem and recommend corrective action, if the problem is deemed to be of significance, to the program director and report back at the next Quarterly meeting.

CDE may recommend the following actions to the Program Director:

A. Promotion with honors

Residents with superior performance in all areas of evaluation throughout the year will be recommended for promotion with honors. Residents receiving promotion with honors will be given priority consideration for employment as Chief Resident, Assistant Chief Resident, and Faculty.

B. Promotion

Residents with consistently acceptable performance in all areas of evaluation will be recommended for promotion.

C. Intensification of evaluation

CDE may recommend more intensive monitoring of a resident's performance as a corrective action. This may take the form of requiring the resident to be observed more frequently in any setting (e.g., during Family Health Center) or while performing a given procedure; or it may involve requiring the resident to take and pass written or oral examinations in subject matter defined by the faculty; or it may take any other form recommended by CDE and approved by the program director.

D. Repeat of a rotation

CDE may recommend that a resident be required to repeat a specified rotation as a corrective action. CDE may recommend that the rotation be repeated in lieu of elective time or that the rotation be repeated in additional time, delaying promotion or graduation. No more than one rotation may be repeated at the expense of elective time.

E. Specific remedial activity

CDE may recommend that a resident be required to undertake and perform in a satisfactory manner specific tasks of remediation as a corrective action. CDE may recommend that time required to perform these tasks be deducted from other required or elective rotations or added to the resident's total time period in the program.

F. Delay in promotion

CDE may recommend delay in promotion as a corrective action. Delay in promotion shall be recommended when a resident's performance is less than that consistent with the level of independence expected at the higher PGY level.

G. Supervision of specified activities

CDE may recommend that a resident be directly supervised by another physician when performing specified tasks or activities as a corrective action. Such direct supervision shall be recommended when there is a doubt as to the ability of the resident to perform the specified tasks or activities unsupervised.

H. Probation

CDE may recommend that a resident be placed on probation as a corrective action. CDE will recommend probation in cases where the resident's ability to meet the requirements of the program is in doubt. CDE will recommend the length and conditions of said probation including requirements that the resident must meet in order to avoid dismissal from the program.

I. Suspension

CDE may recommend suspension from the program as a disciplinary action. Suspension will be for a specified length of time. Generally suspension will be employed in cases where a resident has violated a policy, e.g., for failure to complete medical records in a timely fashion.

J. Dismissal

CDE may recommend dismissal from the program as a disciplinary action. Generally CDE will recommend dismissal in cases where one or more other corrective actions have been recommended and employed but where the resident's performance has failed to improve. CDE may, however, recommend dismissal as a consequence of flagrantly unacceptable conduct.

X.     Awards:

At the Annual Graduation Awards Ceremony the CDE Committee will present the following awards to three graduating Family Practice Residents.

1. Society of Teachers of Family Medicine Resident Teaching Award


2. Academic Award


3. Ayman Elotei, M.D. Award


4. Dr. Goetz OB Award

Senior Research Project

Policy Statement

All Family Practice residents are required to complete a research project before the conclusion of their training program.

Purpose of Policy

Accreditation guidelines indicate that each program must provide opportunity for residents to participate in research or other scholarly activities. Instruction in the critical evaluation of medical literature, including assessing study validity and the applicability of studies to the residents' patients, must be provided.

The participation of each resident in an active research program should be encouraged as preparation for a lifetime of self-education after the completion of formal training. This experience should be designed to give the residents an awareness of the basic principles of study design, performance, analysis, and reporting, as well as of the relevance of research to patient care. Other acceptable forms of scholarly activity include presentations at national, regional, state, or local meetings, and presentation and publication of review articles and case presentations.

Policy Details

In order to fulfill this requirement, the following steps must be completed:

Residents must:

1. Give an oral presentation of their research study at the Flint Community Research Day given in the spring of each year.


2. Provide a written paper suitable for publication that describes their research project and findings. This paper must be submitted to the Director of Research and Family Practice Program Directors by June 1^st for review and approval. If the paper is not approved as written it will be returned for revisions.


3. Once the paper is judged acceptable by the Director of Research and Program Directors, a copy of this paper must be submitted to the Director of Curriculum Development and Evaluation along with a form indicating that that the research requirement has been successfully completed. This notification is necessary before residents can receive their residency certificate of graduation.

Failure to follow this policy will effect the completion of your training program and the ability to sit for the ABFP and/or ACOFP certification exam.

Family Practice Educational Day Policy

Policy: All Family Practice Residents are required to attend the monthly Family Practice Educational Day (typically held at MSU/COM).

Purpose: To provide Family Practice Residents across the State of Michigan with high quality didactics and skill workshops.

Attendance Requirement:

All residents are expected to attend. The only residents excused from attending are those assigned to night float rotations, out on approved vacation time (PTO), personal illnesses (see FP sick policy), approved leave (i.e. bereavement, maternity, etc.), and out-time at a location greater than a 50 mile radius with pre-approval of the Family Practice Program Director(s).

The Program Director(s) must be notified in advance. Unexcused absences will result in the assignment of one jeopardy call.

An eighty percent (80%) average over three (3) years attendance is required for the Statewide Campus System Family Practice Educational Days. This includes excused absences. The CDE Committee will review attendance on a regular basis and make recommendations to the Program Directors.

Patient Care Responsibilities:

Family Practice Residents on General Medicine, Pediatrics, OB and covering FHC patients must see and complete notes on their patients prior to departing for SCS Family Practice Educational Days.

Pager Coverage:

Pagers are passed to covering interns/attendings at 6:45 a.m. in the Doctor’s Dining Room. Pagers are then picked up by the Night Float Team at 5:00 p.m. that day, also in the Doctor’s Dining Room. Covering Interns are assigned at the beginning of the year.

Family Medicine Requirements for Logs

Policy: Each Family Practice Resident is required to document and maintain a log of all procedures, admissions, consultations and patients where they have had significant care responsibilities. This includes those you observe, assist or perform in both the inpatient and outpatient settings. These logs must be submitted at the end of each block and will be reviewed by the Director of Medical Education and the Program Director(s). Duplication of another resident’s log is considered unprofessional and fraudulent.

Logs may differ for first year osteopathic interns according to the AOA requirements. (See AOA Internship Log located in this manual).

OMT done by interns and residents both in the inpatient and outpatient settings must also be logged.

Procedure: Procedures, admissions and consultations must be documented in a log using the form supplied by Medical Education (please note there are different forms by PGY status and for AOA residents). A printed output of an electronic version with all of the same information as the required form is an acceptable substitute.

Currently all PGY 1 and 2’s are to use New Innovations for logging

Residents are encouraged to document all patient encounters both in hospital and outpatient particularly for continuity patients.

All logs must be submitted (completed) to CDE Section of Medical Education at the end of each block. Residents whose logs are overdue greater than one block will be assigned a jeopardy call for each additional day overdue. Residents will also be held accountable to the Procedure Log Compliance Policy in the Department of Medical Education’s Administrative Manual.

Log completion and content will be reviewed at each Quarterly Meeting of the Program Director and the resident.

Family Practice Residency Lecture Attendance Policy

POLICY: All Family Practice Residents are required to attend ALL morning lectures, Wednesday afternoon educational conferences, MSU-COM SCS Family Practice Educational Day (formerly known as COGMET), and noon lectures regarding Ethics.

PURPOSE: To provide Family Practice Residents with high quality didactics and skill workshops in all areas of Family Practice.

ATTENDANCE REQUIREMENT: All residents must attend all the required lectures. Residents can be excused from morning lectures and required noon lectures (Ethics) if they are on sick leave, on vacation, emergent patient care, ER rotation, ICU rotation, or doing an outside rotation (defined as 50 or more miles from Genesys Health Park). Residents can also be excused from Wednesday afternoon educational conferences if they have aforementioned reasons or if they are post-call, part of the skeleton crew, or on the Ambulatory Surgery rotation. Residents who are on surgery rotation can be excused from morning lectures except Wednesday Morning Surgical Grand Rounds. Specific policy regarding COGMET is already in place. You must follow that policy for COGMET attendance.

Residents must report to work no later than 7:00 a.m., sign-in for morning lectures by 7:15 a.m. Conference attendance sheets for morning lectures will be removed at 7:20 a.m. For required noon lectures, residents need to sign-in by 12:15 p.m. Sign-in sheets will be picked up at 12:20 p.m. For Wednesday afternoon conferences, sign-in is at 1:15 p.m. Sign-in sheets will be removed in the end of that day.

IMPLEMENTATION:

This policy will be strictly enforced! To ensure this, random spot checks will be done from time to time by program directors or his designee. If a resident fails to attend a required lecture without legitimate excuses for the first time within an academic year, he or she will be given a written notice. If a second unexcused absence is found in that academic year, he or she will be placed on either additional skeleton crew assignments or jeopardy call at program director’s discretion. In addition, a summary of resident’s lecture attendance will be presented at the quarterly faculty meetings. The records will go into resident’s file and be part of program director's recommendation letter for employment.

Resident should only sign in for those lectures that he or she has actually attended. Random spot checks will also be done from time to time to ensure residents do not violate this rule. If a resident sign in for a lecture that he or she is not in an attendance, the resident will be placed in both additional skeleton crew assignment AND jeopardy call at program director’s discretion. Such unprofessional behavior will also be recorded in the resident’s permanent file and be part of program director's recommendation letter for employment.

Rotation Reading Assignments and Rotation Quizzes Policy

Policy: All Family Practice Residents must complete all Rotation Quizzes.

Purpose: To provide Family Practice Residents with a structured didactic reading resource specifically designed for the broad spectrum of family practice.

Rotation Reading Assignments and Rotation Quizzes

1. For each rotation the assigned AAFP monograph readings and quizzes are to be completed by the end of each 4-week block.


2. A pass rate of 90% on all the assigned AAFP monograph quizzes is required for successful completion of the rotation


3. Completed quizzes are to be turned in no later than the last FRIDAY of each block


4. Failure to submit the Rotation Quiz and Rotation Evaluation by the last Friday of the block will result in an immediate Jeopardy Call for each working day late.


5. For extenuating circumstances only, late submission of quizzes must have prior approval of the Program Director(s).


6. Completion of all Rotation Quizzes is a requirement for promotion or graduation.


7. The assigned rotation specific monographs are listed in the rotation manual.


8. Success completion of the monograph readings and quizzes are required for determination of basic knowledge mastery as well as one of the requirements for academic promotion and graduation.

Note: The AAFP Monograph series is provided to you as a concise educational resource that is specific to Family Practice. The American Family Physician monographs are designed to provide family physicians with high-quality continuing medical education that reflects the spectrum of family practice. For more information, in general, about the monograph series please visit the AAFP web site at http://www.aafp.org/afpmonographs.xml

Family Practice Residency Resident/Staff Meeting Attendance Policy

POLICY:

All Family Practice Residents are required to attend ALL residents/staff meeting which is held every second Thursday of each block. The meeting starts at 7:30 a.m. and ends at 8:30 a.m., which takes place on EFC. All residents are also required to read the meeting minutes and follow the decisions made at each residents/staff meeting.

PURPOSE:

To provide Family Practice Residents and staff with a forum to discuss FHC operational issues. To enhance communications between residents and staff.

ATTENDANCE REQUIREMENT:

All residents must attend All the residents/staff meetings. Residents can be excused from this meeting if they are on sick leave, on vacation, having in- training exams, providing emergent patient care,  on Hurley rotations or doing an outside rotation (defined as 50 or more miles away from Genesys Health Park). All residents on medicine and pediatric services must attend the residents/staff meeting unless they carry on-call pager that day. It is resident’s responsibility to let supervising attending know that you are required to attend residents/staff meeting.

Residents are expected to report to the meeting no later than 7:15 a.m., and must sign in with your time of arrival. Sign in sheet will be available for you at each meeting. Sign in sheet will be taken away at 7:30 a.m.

IMPLEMENTATION:

This policy will be strictly enforced! To ensure this, random spot checks will be done from time to time by FHC medical director or his designee. If a resident fails to attend a residents/staff meeting without legitimate excuses for the first time, he or she will be given a written notice. If a second unexcused absence is found, he or she will be placed on jeopardy call. In addition, a summary of resident’s attendance will be presented at the quarterly faculty meetings.  The records will go into resident’s file and be part of the program director's recommendation letter for employment.

APPENDIX 1

FORMAT FOR AN ADULT HISTORY & PHYSICAL EXAMINATION

There are several basic pieces of information that can be joined to establish the proper diagnosis by the clinician.  These are:

A)     History (which must be accurate, skillfully elicited, carefully interpreted, and coherently expressed).

B)     Physical Examination (which should build on the existing information and /provide clues for obtaining additional history).

C)     Ancillary data (routine and special studies, consultations, etc.).

D)    Observations of the Course of the illness (usually less expensive and more rewarding than extensive excursions in the use of ancillary studies, e.g., lab).

Our basic thesis is that the vast majority of clinical problems should and can be resolved by the effective use of the History and Physical Examination. 

In most cases the History should be and is the most productive.  You will find this conclusively and objectively demonstrated when dealing with patients about whom no history can be obtained. 

To put it another way, the diagnosis should be clear based on the Present illness and related points of the History most of the time.  In fact, if the diagnosis is not apparent at the end of the History and the Physical Examination, there is little likelihood that such will emerge by the use of ancillary data/or special studies. 

Laboratory studies should be viewed and used primarily to confirm a diagnosis rather than make one. Furthermore, experience has taught us that thoughtful observation of the patient and his or her illness can be the most effective tool of complex, particularly chronic, problems.

HISTORY

CHIEF COMPLAINT

This is the first sentence of the write-up and identifies the patient by age and sex and also briefly characterizes the most important complaint in the patient’s own words including its duration in hours, days, months or years.  The Chief Complaint is the ‘marquee’ outside of the theater and should capture the essence of why the patient presented to the hospital or the physician for care.  It sets up the remainder of the History and Physical and poses the questions that the remainder of the record will attempt to answer.  It is a short and focused – ‘one liner’ or a single sentence.   The Chief Complaint is typically one symptom although rarely a ‘symptom complex’ is used in the case for example of endocarditis or a connective tissue disease.  The Chief Complaint is not a diagnosis, laboratory value, or anticipated treatment.  It must be accurately defined in terms of its nature and duration.  The patient’s own words are important; however, the physician must be primarily concerned with interpreting, translating, and formulating the “proper: Chief Complaint.

One must be always aware of the problem of semantics.  For example, does “pooped out” mean muscular weakness shortness of breath, or simply a lack of desire for physical activity?

Examples of a Chief Complaint include:

A)     This is the first GRMC-Health Park admission for this 45-year-old white male who presents with a three-day history of a nonproductive cough.

B)     This 75-year-old white male was in his usual state of health until five hours prior to admission when he developed the acute onset of substernal chest discomfort.

Strategically and appropriately, placed adjectives may further enhance the Chief Complaint. 

For example:

“This 25 year old white male presented with the Chief Complaint of shortness of breath over two weeks prior to admission.” 

This Chief Complaint seems less directive and vaguer than one that reads: “This 25 year old white male homosexual was admitted with a two week history of shortness of breath.”  Clearly one would think about Pneumocystis pneumonia in this latter Chief Complaint. 

Similarly, a 55-year-old white male with a long history of cardiac disease who presents with a Chief Complaint of chest pain is more directive than simply a 55 year old white male who presents with four hours of chest pain as a Chief Complaint.

The physician may interpret the patient’s Chief Complaint.  In other words, the complaint that may initially have brought the patient to the hospital may wind up not to be the major problem that is written about. 

For example, a patient who has a complaint of sinus difficulties as a reason for coming to the doctor, but who on chest x-ray is found to have a lung cancer may end up with a Chief Complaint of increasing shortness of breath occurring over the past one month.

PRESENT ILLNESS

The process of history taking serves several purposes.  Some of these are:

A)     It begins to establish a level of “communication” and a relationship with the patient that will provide important insights into the functional and feeling status of the patients; this enhances one’s understanding of the patient as a person.

B)     It must become the single most valuable source of diagnostic information.

C)     It does provide some focus for the physical examination to be more intensive in certain areas.

D)    It guides one’s selection of future studies of an ancillary nature.

E)     It can elicit important information and provides direction for prevention/intervention of illness in the future.

The Present Illness therefore gives the relevant history of the major problem that will be dealt with during the admission.  It is chronological starting from the onset of symptoms and ends when the patient is admitted to the hospital i.e. what was it that finally brought the patient to the hospital.

The Present Illness traces the development over time of all relevant symptoms and any stimulating or relieving factors that affect them and any remedies that were tried and their effects.  It must include either during the text or at the end a listing of pertinent negative and positive symptoms.  It should not however include laboratory or treatment rendered in an Emergency Room.  It should be specific to and further describe the Chief Complaint.  Certainly problems and symptoms should be “lumped” together and included if available data suggest that they share a common etiology or cause.  However, do not include irrelevant symptoms in the Present Illness.

Rhetoric is important when writing up a History and Physical and good English should be rigorously practiced.

As relates to chronology in the Present Illness, this should not be written in terms of dates, but rather sentences should be front-ended by the time of onset of a symptom in terms of days, months, hours or years.  For example, five hours prior to admission the patient developed the acute onset of right-sided chest pain.  It is preferable not to have the time duration towards the end of a sentence but rather at the beginning.

There are several factors influencing the effectiveness and efficiency with which a physician obtains a history.  These may include:

A)     The presence or lack of an organized approach to collecting data which obviously depends on the proper use of a differential diagnosis during history taking.

B)     The patient’s attitudes towards physicians, the illness, the specific physician involved, and other health personnel.

C)     The physician’s attitude towards the patient, the type (age, sex, social status) of patient he/she is, the illness involved, etc.

D)    The level of interest, warmth, and/or empathy that the physician displays towards the patient.  Patients are quite perceptive and unusually sensitive to deviations from a genuinely open and honest approach.

E)     The level of mutual respect.  The physician should display a polite and honestly friendly concern in an intellectual and objective manner.       

Above all, it must be stated that patients are never poor historians- only doctors are!

Overall, the timing, sequence, chronology, and proper language are the essential ingredients to a cogent Present Illness.  In short, the Present Illness must add up to something that is identifiable as an illness.  One must ask “does it add up to something that can be identified?”  The following must be kept in mind.

A)     Most diseases have a relatively constant and predictable natural history.  Their expressions through patients in the form of illness become the Present Illness.

This expression of a disease will however vary from patient to patient presenting a challenge to the clinician in that it requires the ability to help the patient translate subjective complaints like diarrhea into objectively describable parameters.  Pain must be fully described in terms of frequency, onset, relieving and exacerbating factors, etc.  Symptoms such as shortness of breath described in terms of change in exercise tolerance, diarrhea in terms of volume and frequency of stools. Phlegm in terms of amount and color are all-important.  Subjective historical expressions such as weakness, pain, strange sensations, flu, etc are generally imprecise.  This presents a challenge to the clinician in that he has to help the patient translate the subjective complaints into objectively describable parameters.  Weakness as a symptom for example can have many different meanings and can reflect respiratory failure, muscular weakness, or lack of desire.  This must be fathomed out in the Present Illness.

PAST MEDICAL HISTORY

The Past Medical History may be subdivided into Pertinent Past Medical History and Past Medical History. 

Pertinent Past Medical History tends to occur directly after the Present Illness if it directly pertains to it.  This may include past cardiac events in a patient with a complaint of chest pain. 

Otherwise, the Past Medical History lists all other important past medical events.  It should be written in a list form not as a narrative.  It gives a quick overview of significant health events and care.  It should include the year of diagnosis of a medical problem or the year a surgical procedure was performed. 

Developmental history for pediatric patients should also be noted.

MEDICATIONS

This should list dosage and schedule and should include over the counter medications.  Simply stating “takes a water pill” is unacceptable.  If the dosage is not known, contact the pharmacy to get the dosage.

ALLERGY / IMMUNIZATIONS

Specifically list allergies to medications.  Also, list the reaction, if known.  Remember that an individual may have an intolerance (e.g. GI upset to Erythromycin), that he/she may misperceive as an “allergy”.  An intolerance may also be listed, but please label it as such.

Comments should be made regarding age appropriate immunizations.

SOCIAL HISTORY

A personal and social history should then be presented.  In instances in which there are obvious interactions between the patient’s family and social situation and the acute illness (e.g., psychiatric problems), this information would have been presented as part of the HPI.  The main goal of this section is to understand the patient as a person.  Identification of potential problems and coping mechanisms for dealing with illness should be discussed and should include the following areas of emphasis:

A)     Background: birthplace, family setting, cultural background, education, residences, jobs, significant travel.

B)     Current Setting: health of spouse, other intimate relationships, family members, and living circumstances.

C)     Occupation: type, security, satisfaction, finances, insurance.

D)    Recreational hobbies and activities.

E)     Quality of intimate relationships: number of, satisfaction with, sexual concerns.

F)     Other social supports.

G)    Health insurance and relevant personal financial information.

Example: The patient is married and lives with his wife and three children in their own home in Hilt, Michigan.  He is employed as a general manager of a local super market where he has worked for seven years.  He denies any current marital, family or economic stresses and has BC/BS insurance.

Substance use: alcohol, tobacco, and illicit drugs.

FAMILY HISTORY

A screening for inheritable diseases: Allergies, Alcoholism, Birth Defects, Cancer, Depression, Diabetes Mellitus, Epilepsy, Gout, Hypertension, Heart Disease, Renal Disease, Stroke, TB.

ROS (Review of Systems)

If a specific organ system was already investigated in the HPI, you may simply write, “As noted in the HPI-see above”.  Otherwise, you must list everything. 

Simply writing “ROS” is non-contributory/unremarkable” is not acceptable at your present level of training.  Remember that actual disease entities (e.g. glaucoma) belong in the PMH-Illness section. 

The ROS is reserved for symptoms.

GENERAL

Weight change, weight loss, weakness, fatigue, fever, chills, rigors, night sweats

SKIN

Color change, eruptions, rash, pruritus, scaling, bruising, bleeding, lumps, sores, changes in hair color, texture of distribution, hare loss, changes in nail color, pitting, ridging, brittleness or abnormal curvature of the nails

HEAD AND NEUROPSYCHIATRIC

Headache, head injury, syncope, vertigo, focal weakness or paralysis, paresthesias, anaesthesias, convulsions, tremors, involuntary movements, disturbances of smell or taste, imbalance, difficulty in chewing or swallowing, difficulties in speech, loss of memory, atrophy, difficulty in walking, unexplained pain, incontinence of stool or urine, moodiness, insomnia, impotence, hallucinations, delusions, nervous breakdown, anhedonia

EYES

Loss of vision, tunnel vision, color blindness, diplopia, hemianopsia, trauma, glasses, redness, pain.

EARS

Hearing loss, tinnitus, vertigo, discharge, pain, hearing aid use, operations

NOSE

Coryza, rhinitis, epistaxis, trauma, discharge

THROAT, MOUTH AND TEETH

Hoarseness or change in voice, sore throats, bleeding gums, caries, extractions/dentures, dry mouth, and sore tongue

NECK NODES, ENDOCRINE

Lumps, swollen nodes, goiter, neck pain or stiffness, problems with growth, abnormal growth of head, hands, or feet; changes in hair distribution or shin color; intolerance of heat or cold, polydipsia, polyphagia, polyuria, excessive thirst or sweating

BREASTS: (Females)

Lactation, trauma, lumps, self-examination, nipple discharge or retraction, pain

RESPIRATORY

Chest pain, shortness of breath, wheezing, dyspnea of exertion, cough, sputum color and quantity, hemoptysis, tuberculosis exposure, last CXR or TB test

CARDIOVASCULAR

Palpitations, tachycardia, chest pain, orthopnea, paroxysmal nocturnal dyspnea, cyanosis, ascites, edema, claudication, cold extremities, murmur, last EKG

GASTROINTESTINAL

Change in appetite, dysphagia, dyspepsia, regurgitation, weight loss, nausea, belching, vomiting, hematemesis, food intolerance, flatulence, abdominal pain, jaundice, diarrhea, melena, hematochezia, change in stool color, consistency or caliber, hemorrhoids, constipation

URINARY

Change in color of urine, hematuria, dysuria, flank pain, nocturia, pyuria, frequency, urgency, hesitancy, retention, incontinence, decreased stream force

GENITAL (MALE)

Hernias, penile lesion or discharge, testicular pain or mass, self-exam, sexual preference, impotence

GENITAL (FEMALE)

Menstrual history including menarche, cycle length and regularity, duration and quantity of menses, LMP, PMP dysmenorrhea, intermenstrual bleeding and menopause; contact bleeding, postmenopausal bleeding, abnormal bleeding, vaginal discharge, leukorrhea, itching, sores, lesions; h/o DESCRIBED exposure; OB history including number of pregnancies, live births, still births, voluntary and spontaneous abortions, complications of pregnancy and delivery; contraception, contraception, sexual preference, sexual dysfunction, dysparunia

MUSCULOSKELETAL

Myalgias, arthralgais; stiffness, redness, warmth, swelling, or limitations of motion of joint; muscle weakness or atrophy; back pain, night cramps

PHYSICAL EXAMINATION

Several points concerning the Physical Examination merit emphasis:

A.     The process should be:

1.      Explained to the patient.

2.      Comfortable for the patient and you.

3.      Carried out with courtesy, gentleness and propriety.

4.      Carried out in a sequence that is in your style but that will ensure that all systems are examined.

B.     The Physical Examination should be carried out in a thorough and relevant fashion not neglecting other systems.  It should be most intense in the area of suspicion as to the complaints and history obtained to that point.

C.     Perhaps the most important consideration is to know one’s level of expertise in all aspects of the Physical Examination (e.g., how good are you at feeling a spleen or detecting early mitral stenosis? etc? etc?).

D.     The Physical Examination should be used to test the hypothesis(es) formulated from the history in addition to screening for major and minor abnormalities.

The Physical Examination should be performed as completely as possible at the time of hospital admission.  It should include at least the items below.

GENERAL

A general description of the patient should include signs of acute distress, general state of health and nutrition, and state of hydration.  It may be helpful to note unusual behaviors or deformities here

VITAL SIGNS

Accurate vital signs are the responsibility of the resident (not the nurses) and must be recorded here including temperature, pulse, respiratory rate (count it yourself), blood pressure (repeat it yourself if abnormal), and measured weight.  A stated height is acceptable in most adults.

SKIN

Examination of the naked patient is the rule.  Presence of jaundice or other abnormal color, rashes, or lesions should be noted.

HEAD, EARS, EYES, NOSE, AND THROAT

Should include signs of head trauma, inspection of tympanic membranes, nasal passages and throat.  Funduscopic exam should be attempted on every patient.

NECK

Must include mention of thyroid size and shape, neck pulses, JVD.

NODES

At a minimum must include mention of cervical and axillary nodes.  Other areas must be checked when relevant.

CHEST

Must include mention of inspection and auscultation in the typical “IPPA” format.  Use of accessory muscles of respiration may be mentioned here or in general description, along with retractions and flaring.

HEART

Must include at a minimum mention of auscultation including murmurs

BREASTS (FEMALES)

Must be done as part of a complete examination of a female.  Should include mention of masses, skin or nipple changes.

ABDOMEN

Must include mention of bowel sounds, masses, hepatosplenomegaly and tenderness.  Liver span in centimeters in the mid-clavicular line is mandatory.

GENITALIA (MALES)

Must be done as part of a complete examination of a male patient.  Should include mention of hernias, scrotal masses, penile lesions or discharge.

PELVIC (FEMALES)

Must be done as part of a complete examination of a female patient.  Minimum exam is bimanual palpation.  Speculum exam with cultures must be done on any female with a fever, abdominal pain or a discharge, at the time of admission.  Any female with a cervix must have a Pap smear before discharge unless one has been done within the last year.

RECTAL

Must be done on every patient as part of a complete examination.  Should include a guiac test.

EXTREMITIES

Must include mention of peripheral pulses and edema, as well as any gross asymmetries or deformities.

NEUROLOGIC

Must include examination of mental status, motor, sensory, cranial nerves, coordination and reflexes.

INITIAL LAB AND X-RAY (ancillary data)

Ancillary data includes:

A)     Laboratory data

B)     Special studies

C)     Consultations

Ancillary studies should not be used in a shotgun fashion or without consideration to costs/benefits ratio.  Unfortunately, it is not infrequent that ancillary data is ordered prematurely and/out of context or without rational.  Therefore, keep in mind the hypothesis that you are testing when you write orders.  Literally, almost every patient that comes into the hospital should receive some baseline screening tests including urinalysis, CBC, lytes, BUN, creatine, and glucose.  Other laboratories will be performed as appropriate to the case.

ASSESSMENT

The Assessment should be a brief statement of what diagnostic possibilities seem most likely.  It may include a general statement of your approach to the diagnostic plan. 

The History and Physical findings do not need to be reviewed here; however, your diagnostic thinking should be outlined and certainly will be evident in more detail in your plans for problem evaluation. 

A discussion of the most probable cause and important alternative possibilities should be included. 

The Assessment should not simply be a listing of problems identified.  Relationships among problems are important to include in sections of the record.

PLANS

Plans for each problem should be divided into a) a diagnostic plan, b) a treatment plan and c) a patient education plan.  The diagnostic plan should include a rationale for each test, showing how it can be expected to further define the nature of the problem.

An appropriate initial treatment plan should be presented.  It should include the following aspects: 1) activity level; 2) diet; 3) medications; 4) other therapy (respiratory, PT/OT, etc) and 5) IV orders.  The risks and benefits of procedures and treatments should be discussed.

The treatment plan should include patient education and should state what the patient was told.  In addition, the resident should present any pertinent long-term implications of the major problems in terms of the patient’s 1) expected course; 2) self-image; 3) role in the family and the community: and 4) financial situation.  The utilization of family and community resources in the patient’s ongoing care should be discussed.

Diagnostic tests that are planned should each be connected to the diagnosis being evaluated by that test.

Example:  Rule out MI: Admit to coronary care unit.  Daily serum enzyme determinations and EKGs.  Chest X-ray to R/O CHF.

Example:  Abdominal pain.  Barium enema and sigmoidoscopy with possible biopsy to rule out inflammatory bowl disease.

Treatment should include all medications, surgery, physical therapy or other treatments being directed towards the problems at hand.

Example:  Demerol 50mg.  IM Q4H as needed for abdominal pain.

Example:  Begin Inderal 40mg each morning for blood pressure.

APPENDIX 2

FORMAT FOR A PEDIATRIC HISTORY & PHYSICAL

History

A sympathetic listener who addresses the parent and child by name frequently obtains more accurate information than does a harried, distracted interviewer. Careful observation during the interview will often uncover stresses and concerns that otherwise are not apparent.

The history usually is learned from the parent or the caretaker of a sick child. For the acutely ill child, a short, rapidly obtained report of the events of the immediate past may suffice temporarily, but as soon as the crisis is controlled, a more complete history is necessary.

A well-organized record facilitates the retrieval of information.

The following guidelines indicate the necessary information and the order of presentation.

General

Identifying data: age and birth date, sex, race, relationship of the child and informant, and some indication of the mental state or reliability of the informant.

Chief Complaint

Given in the informant or patient's own words. A brief statement of the reason why the patient was brought to be seen.

Expanding the question of "Why did you bring him?" to "What concerns you?" allows the informant to focus on the complaint more accurately. Carefully phrased questions can elicit information without prying.

History of Present Illness

The details of the present illness are recorded in chronologic order. For the sick child, it is helpful to begin: "The child was well until "X" number of days before this visit." This is followed by a daily documentation of events leading up to the present time, including signs, symptoms, and treatment, if any. Statements should be recorded in number of days before the visit or dates.

If the child is taking medicine, the amount being taken, the name of the medicine, the frequency of administration, and how well and how long it has been or is being taken are needed.

For the well child, a simple statement such as "No complaints" or "No illness" suffices. A question about school attendance may be pertinent.

If the past medical history is significant to the current illness, a brief summary may be included.

Past Medical History

Obtaining the past medical history serves not only to provide a record of data that may be significant either now or later to the well-being of the child, but also to provide evidence of children who are at risk for health or psychosocial problems.

Prenatal History

Question about the health of the mother during this pregnancy, especially in regard to any infections, other illnesses, vaginal bleeding, toxemia, or care of animals

The number of previous pregnancies and their results, radiographs or medications taken during the pregnancy, results of serology and blood typing of the mother and baby, and results of other tests such as amniocentesis should be recorded.

Mother's weight gain excessive or insufficient.

Neonatal History

Apgar scores at birth and at 5 minutes.

Any unusual appearance of the child such as cyanosis or respiratory distress, and any resuscitative efforts that took place and their duration

Jaundice, anemia, convulsions, dvsmorphic states, and congenital anomalies or infections in the mother or infant.

Feeding History

Note whether the baby was breast- or bottle-fed.

Poor sucking at the first feeding may be the result of sleepiness of the baby, but also is a warning sign of neurologic abnormality, which may not become manifest until much later in life. By the second or third feeding, even brain-damaged children usually nurse well.

If the infant has been bottle-fed, inquire about the type of formula used and the amount taken during a 24-hour period. At the same time, ask about the mother's initial reaction to her baby, the nature of bonding and eye-to-eye contact, and the patterns of crying, sleeping, urinating, and defecating. Requirements for supplemental feeding, vomiting, regurgitation, colic, diarrhea or other gastrointestinal or feeding problems should be noted.

Determine the ages at which solid foods were introduced and supplementation with vitamins or fluoride took place, as well as the age at which weaning.

If feeding difficulties are present, determine the onset of the problem, methods of feeding, reasons for changes, interval between feedings, amount taken at each feeding, vomiting, crying, and weight changes. With any feeding problem, evaluate the effect on the family by asking, "How did you manage the problem?"

For an older child, ask the informant to supply some breakfast, lunch, and dinner (supper) menus, likes and dislikes, and response of the family to eating problems.

Developmental History

Estimation of physical growth rate is important. These data are plotted on physical growth charts. Any sudden gain or loss in physical growth should be noted particularly, because its onset may correspond to the onset of organic or psychosocial illness. It may be helpful to compare the child's growth with the rate of growth of siblings or parents.

Ages at which major developmental milestones were met aid in indicating deviations from normal. Some such milestones include following a person with the eyes, holding the head erect, smiling responsively, reaching for objects, transferring objects, sitting alone, walking with support and alone, speaking the first words and sentences, and experiencing tooth eruption. Ages of dressing self, tying own shoes, hopping, skipping, and riding a tricycle and bicycle should be noted, as well as grade in school and school performance.

In addition, note should be made of the age at which bowel and bladder control were achieved. If problems exist, the ages at which toilet teaching began also may indicate reasons for problems.

Behavior History

Amount of sleep and sleep problems, and habits such as pica, smoking, and use of alcohol or drugs should be questioned if age appropriate.

The informant should state whether the child is happy or difficult to manage, and should indicate the child's response to new situations, strangers, and school.

Temper tantrums, excessive or unprovoked crying, nail biting, and nightmares and night terrors should be recorded.

Immunization History

The types of immunizations received, with the number, dates, and reactions should be recorded as part of the history.

History of Past Illnesses

Specific inquiry of any history of roseola, rubeola, rubella, pertussis, mumps, varicella, scarlet fever, tuberculosis, anemia, recurrent tonsillitis, otitis media, pneumonia, meningitis, encephalitis or other nervous system disease, gastrointestinal tract disease, or any other illness, as well as specific treatment.

The history of each past illness should include dates of onset, course, and termination. If hospitalization or surgery was necessary, the diagnosis dates, and name of the hospital should he included.

Questions concerning allergies include the occurrence and type of any drug reactions, food allergies, hay fever, and asthma.

Accidents, injuries, and/or poisonings

Family History

The family history provides evidence for considering familial diseases as well as infections or contagious illnesses.

Family diseases, such as allergy; blood, heart, lung, venereal, or kidney disease; tuberculosis; diabetes; rheumatic fever; convulsions; skin, gastrointestinal, behavioral, or mental disorders; cancer; or other disease the informant mentions should be included. Pertinent negatives should be included also.

Social History

Details of the family unit include the number of people in the habitat and its size, the presence of grandparents, the marital status of the parents, the significant caretaker, the total family income and its source, and whether the mother and father work outside the home. If it is pertinent to the current problems of the child, inquire about the family's attitude toward the child and toward each other, the type of discipline used, and the major disciplinarian. If the problem is psychosocial and only one parent is the informant, it may be necessary to interview the other parent and to outline a typical day in the life of the child.

Review of Systems

Eyes

visual changes, crossed or tendency to cross, discharge, redness, puffiness, injuries, glasses

Ears

difficulty with hearing, pain, discharge, ear infections, myringotomy, ventilation tubes

Nose

discharge, watery or purulent, difficulty in breathing through nose, epistaxis

Mouth and throat

sore throat or tongue, difficulty in swallowing, dental defects

Neck

swollen glands, masses, stiffness, symmetry

Breasts

lumps, pain, symmetry, nipple discharge, embarrassment

Lungs

shortness of breath, ability to keep up with peers; cough with time of cough and character, hoarseness, wheezing, hemoptysis, pain in chest

Heart

cyanosis, edema, heart murmurs or "heart trouble," pain over heart

Gastrointestinal

appetite, nausea, vomiting with relation to feeding, amount, color, blood- or bile-stained, or projectile, bowel movements with number and character, abdominal pain or distention, jaundice

Genitourinary

dysuria, hematuria, frequency, oliguria, character of urinary stream, enuresis, urethral or vaginal discharge, menstrual history, attitude toward menses and opposite sex, sores, pain, intercourse, venereal disease, abortions, birth control method

Extremities

weakness, deformities, difficulty in moving extremities or in walking, joint pains and swelling, muscle pains or cramps

Neurologic

headaches, fainting, dizziness, incoordination, seizures, numbness, tremors

Skin

rashes, hives, itching, color change, hair and nail growth, color and distribution, easy bruising or bleeding

Psychiatric

usual mood, nervousness, tension, drug use or abuse

PHYSICAL EXAMINATION

Vital Signs

Temperature

Taken in the axilla or rectum in the young child and by mouth after 5 or 6 years of age.

Elevated temperature occurs with infection, excitement, anxiety, exercise, hyperthyroidism, collagen-vascular disease, or tumor.

Decreased temperature occurs with chilling, shock, hypothyroidism, or inactivity. Temperature may be decreased after taking certain drugs, with hypocortisolism, or with overwhelming infection.

Pulse

The normal rate varies from 70 to 170 beats per minute at birth to 120 to 140 shortly after birth, and ranges from 80 to 140 at 1 to 2 years, from 80 to 120 at 3 years, and from 70 to 115 after 3 years.

For each degree of temperature rise, the pulse rate increases about 10 beats per minute.

The pulse rate is elevated with excitement, exercise, or hypermetabolic states, and is decreased with hypometabolic states, hypertension, or increased intracranial pressure.

Absence of the femoral pulse is a cardinal sign of postductal coarctation of the aorta.

Respiratory Rate

The respiratory rate should be determined by observing the movement of the chest or abdomen or by auscultating the chest. The normal newborn rate is 30 to 80 breaths per minute; the rate decreases to 20 to 40 in early infancy and childhood and then to 15 to 25 in late childhood and adolescence.

Exercise, anxiety, infection, and hypermetabolic states increase the rate.

Central nervous system lesions, metabolic abnormalities, alkalosis, depressants, and other poisons decrease the rate.

Blood Pressure

The blood pressure should be measured with a cuff, with the bladder completely encircling the extremity and the width covering one half to two thirds of the length of the upper arm or upper leg. The pressure should be recorded and compared with normal readings.

High systolic pressure occurs with excitement, anxiety, and hypermetabolic states.

High systolic and diastolic pressures occur with renal diseases, pheochromocytoma, adrenal disease, arteritis, or coarctation of the aorta.

Height, Weight, Head Circumference

To obtain height and weight recordings, measure the infant supine up to the age of 2 years, and standing thereafter.

Measure head circumference in all infants less than 2 years of age and in those with misshapen heads.

General Appearance

A statement should be recorded about the alertness, distress, general development, and nutrition of the child. Mental status, activity, unusual positions, or apprehension or cooperativeness may direct one to consider an acute or chronic illness or no illness at all.

The child who lies quietly, staring into space, may be gravely ill. The child who lies quietly but becomes irritable when held by his mother (paradoxic irritability) might have meningitis or pain in motion.

Skin

Normal color of the skin is the result of the presence of melanin; depigmented areas are vitiligo: absence of pigment occurs in albinism. Cyanosis is caused by unsaturation of or abnormal forms of hemoglobin; jaundice is caused by excessive bilirubin deposited in the adipose tissue. Note the size and borders of nevi, which usually are darkly pigmented areas, and café-au-lait spots, which are brownish areas that may signal neurofibromatosis. White spots shaped like a leaf suggest tuberous sclerosis. Ecchymoses or petechiae and scars may indicate abuse.

Swelling may be caused by edema. Lack of turgor occurs with dehydration or recent weight loss. Describe any rashes, many of which are characteristic of viral or bacterial infection.

HEENT

Head and Face

Record the shape, symmetry, and any defects of the head; the distribution of hair; and the size and tension of fontanelles. A large head may be an early sign of hydrocephalus or an intracranial mass. A small head may be a result of early closure of sutures or lack of brain development. For any deviation from normal head size, frequent measurements are necessary. The fontanelles normally are flat. The posterior fontanelle closes by 2 months of age, and the anterior fontanelle closes by 12 to 18 months of age. Unusual hair whorls are associated with severe intracranial abnormalities.

The face may appear distinctive for a number of syndromes. For example, unilateral facial paralysis may be associated with congenital heart disease. Coarse facies occur with storage diseases. Epicanthal folds occur in a number of syndromes, including Down (5trisomy 21.)

Eyes

Test vision grossly in the young child with brightly colored objects. In the older child, test with Snellen's E chart. Evaluate for strabismus by noting the position of the reflection of light on the cornea from a distant source. Evaluate the range of eye movements and the presence of nystagmus. Both eyelids should open equally. Failure to open is ptosis and may be caused by neurologic or systemic diseases. Upward slanting of the palpebral fissures with covering of the inner canthus (epicanthal folds) is a sign of Down syndrome. The conjunctivae should be pink, but not inflamed; the sclera should be white. Examine the cornea for haziness (a sign of glaucoma) or opacities. Record the size and shape of the pupils, the color of the iris, and the response of the iris to light and accommodation. In the fundiscopic examination, use a zero lens and note the presence of a red reflex, or hemorrhages or pigmented areas, and the size of the veins compared to the arteries. Any obstruction, such as corneal or lenticular cataract will obliterate part of or the entire red reflex. The disc borders should be sharp. They are blurred with increased intracranial pressure. The macula may not be clear, which is a sign of degenerative diseases. Obtain the corneal reflex by lightly touching the cornea with a piece of cotton. Failure to blink indicates trigeminal or facial nerve injury.

Ears

Note the position of the ears and abnormalities of the external ear, the pinna. Low-set ears may suggest the presence of renal agenesis. Tags and deformities frequently are associated with other minor or major anomalies. Grossly evaluate hearing, and then proceed with examination of the inner ear. Pull the earlobe up and anteriorly. Grasp an otoscope equipped with a bright light so that the holding hand rests on the child's head and moves with any movement of the head, and use the largest speculum that will fit into the canal. The canal should be clear, and the drum should be pearly gray in color and concave. A cone of light, the malleus, and sometimes the incus will be identified. If the bones are not visualized, the drum is not gray in color or is infected, or the drum is not concave, fluid may be in the inner ear, which is diagnostic of otitis media.

Nose

Raise the tip of the nose and look up the nose with a bright light. Deformities of the septum, bleeding, or discharges should be recorded. The normal nasal mucosa is light pink in color. Tap on the maxillary and frontal sinuses for tenderness. Feel for air egress from both nares.

Mouth and Throat

Examination of the mouth and throat usually is the most resistant part of the examination and should be performed near the end of the examination. The child should be sitting so that the tongue is less likely to obstruct the pharynx. Deformities or infections around the lips are recorded. Count the number and note the condition of the teeth. Similarly, note the condition and color of the tongue, buccal mucosa, palate, tonsils, and posterior pharynx. Normally, these are pink in color. Exudate indicates infection by bacteria, viruses, or fungi, but etiology usually cannot be determined by physical examination alone. Note also the presence of the gag reflex and the voice or cry. If the child seems hoarse, question the parent concerning the normal voice. Laryngitis can lead to airway obstruction. After the age of 2 years, children should not drool. Chronic drooling may suggest mental deficiency, but acute onset of drooling is a grave sign of epiglottitis or poison ingestion.

Neck

Feel in the neck for lymph nodes, which normally are nontender and up to 1 cm in diameter in both the anterior and posterior cervical triangles. Larger or tender nodes occur with local or systemic infection or malignancies. Feel the trachea in the midline. The thyroid may not be palpable. Other masses may be present and are always abnormal. Flex the neck. Resistance to flexion is a cardinal sign of meningitis, except in infancy, but this also occurs with severe infections around the neck or dislocation of the cervical vertebrae.

Lymph Nodes

In addition to the lymph nodes in the neck, palpate inguinal, epitrochlear, supraclavicular, axillary, and posterior occipital nodes. Normally, inguinal nodes may be up to 1 cm in diameter: the others are nonpalpable or less than 5 mm. Larger or tender nodes hold significance similar to that described for abnormal cervical glands.

Chest

Observe the chest for shape and symmetry. The chest wall is almost round in infancy and in children with obstructive lung disease. Respirations are predominantly abdominal until about 6 years of age, when they become thoracic. Note suprasternal, intercostal, and subcostal retractions, which are signs of increased respiratory work. Swelling at the costochondral junctions is an indication of rickets. Edema of the chest wall occurs in children with superior vena cava obstruction. Asymmetry of expansion occurs with diaphragmatic paralysis, pneumothorax, or other intrathoracic abnormalities.

Breasts

Breasts normally are hypertrophied at birth; they regress within 6 months and develop with the onset of puberty. Development during adolescence is staged. Breast development in both boys and girls usually begins asymmetrically. Palpate for nodules, which may be cysts or tumors. Redness, heat, and tenderness usually indicate infection.

Lungs

Examination of the lungs includes observation, palpation, percussion, auscultation, and, if indicated, transillumination.

Observation

Note the type and rate of the child's breathing. The rate of respiration varies, as described previously. Rapid rates, known as tachypnea, are associated with infection, fever, excitement, exercise, heart failure, or intoxicants. Slower rates are characteristic of intracranial lesions, depression caused by sedative drugs, heart block, or alkalosis. Cheyne-Stokes breathing, which is characterized by periods of deep, rapid respirations followed by slow, shallow respirations, is common in premature and newborn infants, and in those with intracranial or metabolic abnormalities. Dyspnea, or distress during breathing, is associated with flaring of the intercostal spaces and nares. Inspiratory dyspnea is more common with obstruction high in the respiratory system and expiratory dyspnea is more common with lower respiratory diseases.

Palpation

Feel the entire chest with the palms and fingertips. Note masses or areas of tenderness. Tactile fremitus, a vibratory sensation during crying or speaking, normally is felt over the entire chest. Fremitus is absent if the airway is obstructed.

Percussion

Either direct percussion (tapping the chest wall directly with either the index or middle fingers) or indirect percussion (placing a finger of one hand firmly on the chest wall and tapping that finger with the index or middle finger of the opposite hand) may be used in children. The entire chest wall is percussed anteriorly, posteriorly, and along the midaxillary line. A resonant sound will be obtained over most of the chest except over the scapulae, diaphragm, liver, and heart, where dullness is elicited. Dullness detects consolidation in the lungs, as well as the size and position of the liver and heart. Scratch percussion, which involves tapping the chest wall with a finger while listening with a bell stethoscope over the heart and liver, is especially useful in determining heart and liver size. Increased resonance is found with increased trapped air, emphysema, or air in the pleural space (pneumothorax).

Auscultation

To auscultate the lungs in children, listen with a small bell in small children and with the diaphragm in older children. Normal breath sounds are bronchovesicular and inspiration is twice as long as expiration in young children; breath sounds are vesicular and inspiration is three times as long as expiration in older children. Breath sounds are decreased with consolidation or pleural fluid in the young child and increased with pneumonia in the older child. Fine crackles either in inspiration or expiration (rales) indicate foreign substances, usually fluid, in the alveoli or smaller bronchi, as occurs in bronchitis, pneumonia, or heart failure. Coarse extraneous sounds (rhonchi) are the result of foreign substances in the larger airways, as in crying or upper respiratory infection. Musical extraneous sounds (wheezes) are caused by airflow through compromised larger airways, as in asthma.

Transillumination

If pneumothorax is present, the chest will transilluminate. This is especially useful in the newborn.

Heart

In addition to the heart's rate (pulse) and rhythm, and the blood pressure, note the size, shape, sound quality, and presence of murmurs when examining the heart.

Precordial bulging is a sign of right-sided enlargement. A cardiac impulse may not be noted in a young child, but in a thin, active child, it may suggest the size and position of the heart. An apex beat outside the midclavicular line in the fifth interspace indicates cardiomegaly, which is a significant sign of heart disease or heart failure. Palpation and percussion are described above. Auscultate both in the sitting and the supine position. Determine the heart rate and rhythm if this was not done previously. Auscultate initially over the apex (mitral area), then over the lower right sternal border (tricuspid area), the second left intercostal space at the sternal edge (pulmonary area), and the second right intercostal space at the sternal edge (aortic area). Next, proceed to the remainder of the precordium, the axillae, back, and neck. Note heart sounds and any arrhythmia. A loud first sound at the apex occurs with mitral stenosis, a loud second sound at the pulmonary area occurs with pulmonary hypertension, and a fixed split-second sound in the pulmonary area occurs with an atrial septal defect. Innocent murmurs are systolic, musical, or vibratory and of low intensity, and usually are heard at the second left Interspace, just inside the apex, or beneath either clavicle. The latter is a venous hum that may be continuous and that disappears when the patient is supine. Diastolic murmurs are almost always significant. Significant systolic murmurs may be stenotic and are loudest in mid-systole over the aortic or pulmonary areas. Regurgitant murmurs begin immediately after the first sound. Over the mitral or tricuspid area, they indicate valvular insufficiency. A continuous or uneven systolic murmur along the upper left sternal border indicates patent ductus arteriosus.

Abdomen

Observe the shape of the abdomen. A flat abdomen may indicate diaphragmatic hernia; a distended abdomen may indicate intestinal obstruction or ascites. Auscultate before percussing or palpating. Normally, peristaltic sounds are heard every 10 to 30 seconds. High-pitched frequent sounds occur with obstruction or peritonitis; absent sounds indicate ileus. Next, palpate gently, beginning in the left lower quadrant and proceeding to the left upper, right upper, right lower, and midline areas. Then palpate more deeply in the same areas and follow with palpation in the same areas with the unused hand, pushing toward the front hand from the child's back. Feel especially for the liver in the right upper quadrant and the spleen in the left upper quadrant, and estimate their size. Any other masses are abnormal. Determine tenderness and attempt to locate the maximum point of any tenderness, which may indicate intra-abdominal infection such as peritonitis, cystitis, or appendicitis, or rapid enlargement of organs, as occurs with enlargement of the liver in heart failure. Percuss to verify findings. Feel in the costovertebral angles to determine kidney size. Tenderness usually indicates pyelonephritis.

Genitalia

Average adolescent development in girls proceeds as follows:

·         breast development at 10.5 years of age,

·         pubic hair at 11 years of age,

·         increase in height velocity at 12 years of age,

·         menarche at 12.5 years of age

·         axillary hair at 13 years of age.

Average development in boys proceeds as follows:

·         testicular enlargement at 11.5 years of age,

·         pubic hair at 12.5 years of age,

·         increase in height velocity at 14 years of age,

·         facial and axillary hair at 14.5 years of age.

Variations in order of development suggest hormonal abnormalities. Modesty of the child should be respected during the examination, especially of the genitalia.

Inspect the genitalia for urethral discharges, which are always pathologic and indicate infection anywhere in the genitourinary systems.

In a girl, vaginal bleeding after the newborn period and before puberty may be the result of injury or foreign body. Fused labia minora usually part with hygiene. Imperforate hymen causes hydrocolpos before puberty and hematocolpos after menarche. Vaginal discharge may be the result of injury or foreign body in a young girl, usually is normal at the start of puberty, and suggests infection in an older girl. Adolescents with vaginal discharge, dysuria, lower abdominal pain, irregular bleeding, or sexual activity require a complete vaginal examination. The uterus in a younger child is palpated for size, shape, and tenderness with one hand over the lower abdomen and a finger of the other hand in the rectum. For an older child, the cervix is visualized with a vaginoscope or small speculum, and cultures are obtained.

In boys, testes should be in the scrotum after birth, although active cremasteric reflexes may empty the scrotum temporarily. The meatal opening should be slit-like and the urinary stream should be strong. Hydroceles, which do not reduce and do transilluminate, and hernias, which reduce but do not transilluminate, enlarge the scrotum. Testicular tenderness suggests torsion of the testis or epididymitis.

Rectal

Inspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.

Inspect the anus for fissures, inflammation, or lack of tone. The latter may indicate child abuse. The rectum is not examined routinely, but is examined in all children with abdominal or gastrointestinal complaints, including diarrhea, constipation, or bleeding from the rectum.

Extremities and Back

Asymmetry, anomalies, unusual size, pain, tenderness, heat, and swelling deformities of the extremities and back must be distinguished from congenital malformations, osteomyelitis, cellulitis, myositis, or, rarely, rickets and scurvy. Joint heat, tenderness, swelling, effusion, redness, and limitation or pain on motion may indicate arthritis, arthralgia, synovitis or injury, or septic arthritis (which is a medical emergency). Observe as the child walks for the presence of a limp. Clubbing of the fingers is a sign of chronic hypoxemia, as in congenital heart or chronic pulmonary diseases.

The spine should be straight with mild lumbar lordosis. Kyphosis, scoliosis, masses, tenderness, limitation of motion, spina bifida, pilonidal dimples, or cysts may be caused by injury, malformation, infections, or tumors.

Weakness, tenderness, or paresis of the muscles suggests inflammatory muscle disease, congenital or metabolic neuromuscular diseases, or central nervous system abnormalities.

Neurologic Examination

Mental status and orientation help determine the acuteness of a child's illness, depending on the environmental conditions. Position at rest and abnormal movements such as tremors, twitchings, choreiform movements, and athetosis are characteristic of hyperirritability of the central nervous system. Incoordination of gait usually indicates cerebellar dysfunction. Kernig's sign (inability to extend the leg with the hip flexed) and Brudzinski's sign (flexing the neck with resultant flexion of the hip or knee) are indications of meningeal irritation.

Examination of tendon reflexes (biceps, triceps, patellar, and Achilles) is less important than is observation of general activity. Hyperactive reflexes indicate an upper motor neuron lesion or hypocalcemia. Decreased reflexes are seen in lower motor neuron lesions or the muscular dystrophies.

ASSESSMENT

The Assessment should be a brief statement of what diagnostic possibilities seem most likely.  It may include a general statement of your approach to the diagnostic plan. 

The History and Physical findings do not need to be reviewed here; however, your diagnostic thinking should be outlined and certainly will be evident in more detail in your plans for problem evaluation. 

A discussion of the most probable cause and important alternative possibilities should be included. 

PLANS

Plans for each problem should be divided into a) a diagnostic plan, b) a treatment plan and c) a patient education plan.  The diagnostic plan should include a rationale for each test, showing how it can be expected to further define the nature of the problem.

An appropriate initial treatment plan should be presented.  It should include the following aspects: 1) activity level; 2) diet; 3) medications; 4) other therapy (respiratory, PT/OT, etc) and 5) IV orders.  The risks and benefits of procedures and treatments should be discussed.

The treatment plan should include patient education and should state what the patient was told.  In addition, the resident should present any pertinent long-term implications of the major problems in terms of the patient’s 1) expected course; 2) self-image; 3) role in the family and the community: and 4) financial situation.  The utilization of family and community resources in the patient’s ongoing care should be discussed.

Diagnostic tests that are planned should each be connected to the diagnosis being evaluated by that test.

Treatment should include all medications, surgery, physical therapy or other treatments being directed towards the problems at hand.

FORMAT FOR A WRITTEN NEWBORN HISTORY & PHYSICAL

Newborn Exam - Delivery Room

The purpose of the delivery room history and examination is to identify major congenital malformations or other risk factors that would mandate transfer to the Neonatal Intensive Care Unit (NICU) rather than the Newborn Nursery.

Inquire about high risk factors which may be associated with respiratory depression, such as: antepartum fetal bradycardia or tachycardia, meconium-stained amniotic fluid, maternal fever, placental abnormalities, premature or prolonged rupture of membranes (PROM), administration of narcotics, preeclampsia or eclampsia, diabetes, multiparity, use of recreational drugs, abnormal presentation of the fetus.

Scoring system designed by Virginia Apgar ca. 1953 for heart rate, respiratory effort, tone, reactivity, color. By convention, scores are assigned at 1 and 5 minutes, with additional scores given at 5-minute intervals if the most recent score is less than 7.

HISTORY

Inquire about high risk factors which may be associated with respiratory depression, such as: antepartum fetal bradycardia or tachycardia, meconium-stained amniotic fluid, maternal fever, placental abnormalities, premature or prolonged rupture of membranes (PROM), administration of narcotics, preeclampsia or eclampsia, diabetes, multiparity, use of recreational drugs, abnormal presentation of the fetus.

APGARS

Scoring system designed by Virginia Apgar ca. 1953 for heart rate, respiratory effort, tone, reactivity, and color. By convention, scores are assigned at 1 and 5 minutes, with additional scores given at 5-minute intervals if the most recent score is less than 7.

Apgar Score

Physical Examination

General

Petichiae, rash, evidence of birth trauma, lacerations, jaundice?

Weight <1800 gm?

Fontanelle

Bulging, depressed, anterior fontanelle abnormally large (>2x2 cm), posterior fontanelle open?

HEENT

Caput succadaneum? (Soft, ill defined in outline, represents edema of the scalp e.g. often seen after suction extraction)

Cephalhematoma? (Doesn't cross suture lines, usually appears on 2nd day of life.)

Eyes? Ears normally positioned? Nares patent? Cleft lip or palate? Neck masses? NG tube passes OK?

Chest

Breath sounds equal? Good air entry? Presence of stridor, wheezing, flaring, retracting, grunting, cyanosis in room air?

Cardiovascular

Rate >120 and regular? Murmers? Normal PMI?

Femoral pulses easily palpated?

Abdomen

Masses? Size of liver and spleen below mid-costal margin? Distension? Scaphoid?

3-vessel cord?

Genitourinary

If male, testes descended bilaterally? Inguinal masses? Hypospadias?

If female, bulging hymen (imperforate)?

Back

Midline defects? Anus patent?

Neurologic

Alertness? Tone? Symmetric movement?

Erbs Palsy: lack of movement in one arm. Facial palsy?

Moro, grasp, suck, cry, Babinski? Evidence of neural tube abnormalities?

Newborn Exam - Nursery

Measure and record height, weight, and head circumference.

If the infant appears premature or is unusually large or small, perform a Dubowitz/Ballard exam to assess gestational age (see Dubowitz/Ballard scoring grid).

The exam is divided into two parts: an external characteristics score, which is best done at birth, and a neuromuscular score, which should be done within 24 hours after birth.

If the infant appears small evaluate for causes of SGA.

If the infant appears large evaluate for causes of LGA.

SGA - Small for gestational age

Symmetric (HC = Wt = Len, all <10 %ile)

Makes up approximately 33% of SGA infants

• Genetic


• 
  
  Small maternal size


• 
  
  Chromosomal abnormalities (Trisomies 13, 18, 21, and Turner's syndrome)


• 
  
  Congenital abnormalities


• 
  
  Intrauterine infections


• 
  
  Viruses (rubella, CMV, ?varicella, ?HIV)


• 
  
  Bacteria (tuberculosis)


• 
  
  Spirochete (syphilis)


• 
  
  Protozoan (toxoplasmosis, malaria)


• 
  
  Inborn errors of metabolism


• 
  
  Hypophosphatasia


• 
  
  Leprechaunism


• 
  
  Some amino acidurias


• 
  
  Environmental


• 
  
  Drugs (heroin, methadone, ethanol, diphenylhydantoin)


• 
  
  X-rays (therapeutic)


• 
  
  Smoking

Asymmetric (HC = Len > Wt, Wt <10 %ile)

Makes up approximately 55% of SGA infants

• 
  
  Chronic hypertension


• 
  
  Preeclampsia


• 
  
  Renal disease


• 
  
  Cyanotic heart disease


• 
  
  Hemoglobinopathies


• 
  
  Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation.


• 
  
  Altitude

Combined (symmetric or assymetric)

Makes up approximately 12% of SGA infants.

• 
  
  Environmental


• 
  
  Drugs (including ethanol)


• 
  
  Smoking


• 
  
  Placental unit insufficiency


• 
  
  Placental infarcts or chronic abruption, velamentous insertion, circumvallate placenta, multiple gestation.

LGA - Large for gestational age