Pediatric Endocrinology Subspecialty Rotation University of Illinois College of Medicine at Peoria Children’s Hospital of Illinois / OSF Saint Francis Medical Center

Clinic Schedules The week prior to rotating, get ENDO call schedule from Teresa Poshard ([email protected]). Arrive at the clinic 30 minutes prior to review patient’s charts for the day. The charts are located in the patient registration desk area.

Faculty Sue Sauder Joyce Wise Alex Aguilar Roxana Aguirre Valeria Benavides Brian Bostwick

Clinics Hillcrest Medical Plaza* Ped Subspecialty Clinics Suite 401 420 NE Glen Oak Peoria, IL 61603 (309) 624-9844

Gerlach Building Pediatric Diabetes Resource Cntr ** Suite 1141 530 NE Glen Oak Peoria IL 61603 (309)624-2480

General Clinic Days and Hours Monday

Tuesday

Wednesday

Thursday

Friday

AM

Dr. Wise* Dr. Aguilar* Dr. Benavides** Dr. Bostwick**

Dr. Wise** Dr. Aguilar* Dr. Aguirre** Dr. Benavides*

Dr. Sauder** Dr. Aguilar** Dr. Aguirre* Dr. Benavides**

9:00-10:00 Grand Rounds Dr. Sauder**

Dr. Sauder* Dr. Bostwick**

PM

Dr. Aguilar *

Dr. Aguilar * Dr. Benavides*

Dr. Aguirre*

Dr. Aguirre*

Clinic schedules are subject to change. Please ask Teresa Poshard for the monthly schedule. Hormone stimulation testing is performed at the Hillcrest office on Thursday mornings from 8 – 12 AM. Diabetes education sessions are held at the Diabetes Resource Center during business hours from 8 AM to 4 PM.

Rotation Goals and Objectives *Competency Domains: PC = Patient Care MK = Medical knowledge PBL = Problem Based Learning & Improvement ISC = Interpersonal skills & Communication PRO = Professionalism SBP = System Based Practice

1. To familiarize the resident with endocrine disorders and their management in both the outpatient clinics and inpatient services. *PC/MK. 2. To instruct the resident on the practical aspects of diabetes mellitus management. *PC/MK. 3. To develop a system for investigating selected topics in depth using the current literature. *PBLI. Activities 1. Attend all available outpatient clinics at the Hillcrest Medical Plaza and Pediatric Diabetes Resource Center (Easter Seals). Residents are encouraged to review charts before coming to clinic. At the Attending Physician’s discretion, the resident will be the person of first contact with the patient and their families and then discuss any findings with the attending and diabetes team. The resident will coordinate the patient’s care with team members and understand team role members. Residents are responsible for a complete note (including differential diagnosis and plan) on each patient seen. *PC/MK/ISC/SBP. 2. Manage the inpatient service with supervision. The resident will be the person of first contact and responsible for the consult notes and daily progress notes on all endocrine service patients. The resident should formulate a differential diagnosis and plan prior to discussing the patient with the attending and completing the consultation note. The resident will be responsible for reading about the endocrine patient’s disease and serving as the “expert” and advisor for general pediatric service residents. The resident will do any necessary discharge dictations. *PC/MK/ISC. 3. Participate actively in tutorials and case discussions. The resident will be encouraged to research in the current literature and discuss with an attending how the data applies to our patients. *PC/MK/PBLI. 4. Independent Study a. Endocrine curriculum including the 8 basic areas: growth, puberty, thyroid, parathyroid, adrenal, calcium and phosphorus, sex differentiation disorders, and diabetes mellitus type 1 and type 2. b. You will need to choose a topic of your choice for in-depth review and presentation during the rotation. It should be narrow enough to include information at the molecular level as relevant. This needs to be chosen and approved within the first week and will be presented the last week of the rotation. You can use PowerPoint or notes; however, you will be expected to understand the core concepts and be able to answer questions. A list of references used for Page 2 of 11

preparation and a copy of your outline need to be submitted for discussion. Please avoid “reading” your presentation. Visual aids or notes should be used to guide your topic’s discussion. *MK/ICS/PRO/PBLI Endocrine Core Curriculum: PC/MK/PBLI Primary Goal: Understand the role of the pediatrician in prevention, screening and counseling patients and their families with endocrine disorders. Specific Goals I.

GROWTH Goal: Differentiate between normal, physiologic deviations from normal and pathologic findings related to endocrinology A. Short stature  Distinguish among constitutional short stature, genetic short stature, growth hormone failure and idiopathic short stature by growth chart evaluation  Normal variations of growth including familial short stature and constitutional growth delay  Identify proportionate and disproportionate short stature (achondroplasia, hypocondroplasia)  Recognize the signs and symptoms of acquired and congenital growth hormone deficiency  Know the various causes of growth hormone deficiency (idiopathic growth hormone deficiency, growth hormone resistant syndrome, IGF-1 deficiency)  Recognize endocrine dysfunction that affects linear growth such as growth hormone deficiency, hypothyroidism, Cushing’s syndrome, etc. B. Tall stature  Differentiate among the causes of tall stature (i.e. familial, Klinefelter syndrome, acromegaly, Marfan syndrome).

II.

PUBERTY Goal: Recognize the stages of sexual development (sexual maturation rate) using the Tanner staging method among boys and girls A. Normal  Recognize the stages of sexual development  Know the range of age of the onset of puberty among boys and girls in the U.S.

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 Know that peak height velocity in girls occurs earlier in Tanner staging (and chronologically) than in boys  Recognize the methods for assessing the relationship of parental stature to individual adolescent’s stature  Know that Tanner staging in girls (breast and pubic hair) is usually parallel, whereas genital staging usually precedes pubic hair a staging in boys  Know that testicular enlargement is the earliest sign of puberty in boys  Understand that an individual adolescent’s bone age and chronological age may disparate by as much as two years and still be within normal limits  Know there is a genetic influence on the timing of puberty (including age at menarche)  Know that pubertal progression from sexual maturity rating from Tanner stage 2 to 5 can require 2.5 years to complete  Understand the impact of relatively early or late puberty on final adult height  Know that most boys achieve a genital sexual maturity rating (Tanner) of stage 4 prior to the attainment of peak height velocity  Know the sequence of development of secondary sexual characteristics in boys (testicular growth, pubarche, penile growth, peak height velocity)  Know that a testicle of less than 3 ml in diameter or less than 2.5 cm in length is prepubertal  Distinguish between the variations of normal (thelarche, pubarche) and precocious puberty  Know the physiopathology and management of normal vs. abnormal gynecomastia in males  Recognize that pubertal gynecomastia as well as breast development can be asymmetric and that neither indicates pathology  Understand the significance of a breast mass in an adolescent girl  Know the sequence of development of secondary sexual characteristics in girls (breast budding, pubarche, peak height velocity, menarche)  Know that girl’s height will rarely increase more than 2 inches after menarche has occurred  Know that vaginal bleeding in a girl with a sexual maturity rating (Tanner) at stage 2 for breast development is not likely to represent menarche (menarche usually occurs in stage 4)  Know that infrequent menstrual periods within the first 2 years after menarche do not warrant laboratory investigation under most circumstances Page 4 of 11

 Know the preferred treatment of dysfunctional uterine bleeding in adolescence and that surgical intervention is rarely necessary  Know the etiologies of secondary amenorrhea and their respective treatments  Know the characteristics of adolescents with PCOS  Know that the adolescent peak height velocity is more closely correlated with sexual maturity rating stage than with chronological age  Know the average prepubertal height velocity (5-6 cm/year) and the accelerated rate (9-10 cm/year) in the peak adolescent growth spurt and that completion of the pubertal growth spurt takes 2-4 years  Know that the absence of any sign of puberty after the age of about 13 years in a girl or about 14 years in a boy merits investigation  Know that most delayed puberty in boys is constitutional  Know that Turner syndrome can present for the first time as pubertal delay  Understand the limitations of knowing height and weight at only one point in time in assessing a short adolescent (growth velocity is more important that a single measurement)  Know that hormones that accelerate the rate of growth also accelerate closure and have the ultimate effect of limiting growth potential  Know that premature arrest of previously normal growth rate in adolescent demands thorough endocrinologic/neurologic evaluation  Know the psychological risk for boys and girls with delayed puberty B. Precocious puberty  Recognize true precocious puberty versus premature adrenarche  Recognize the tumors that may produce precocious puberty (i.e. idiopathic, hamartomas, craniopharyngioma, granulosa or theca cell tumors) C. Delayed  Recognize the signs and symptoms of delayed puberty due to CNS etiology  Recognize the signs and symptoms of gonadal dysgenesis  Know the laboratory evaluation of gonadal dysgenesis, including karyotype and serum concentrations of LH, FSH, androgens and estrogens  Understand the importance of cardiac and renal disorders in Turner syndrome  Understand the familial influences of the onset of puberty  Recognize the signs and symptoms of constitutional delayed puberty Page 5 of 11

 Know how to use data collection to diagnose and distinguish between constitutional delayed puberty and other conditions III.

THYROID DISORDERS Goal: Understand the general pediatrician’s role in the diagnosis and management of thyroid dysfunction in patients with congenital and acquired hypothyroidism, autoimmunity, hyperthyroidism, thyroid masses and tumor A. Hashimoto’s thyroiditis (Chronic autoimmune thyroiditis)  Recognize the signs and symptoms of Hashimoto thyroiditis  Know the laboratory studies that distinguish among Hashimoto thyroiditis, other causes of thyroid enlargement and hypothyroidism  Know the natural history of Hashimoto thyroiditis  Know how to treat Hashimoto thyroiditis  Know that Hashimoto thyroiditis is the most common cause of goiter in adolescents with a female to male ratio 3-4:1  Know that Hashimoto thyroiditis may be associated with other autoimmune disorders B.

Cyst, tumor  Recognize the signs and symptoms of a thyroid cyst/tumor  Know how to use laboratory evaluation in a child with a thyroid mass  Know the significance of a previous history of irradiation to the head and neck in a patient with a thyroid cyst/tumor  Know that a solitary thyroid nodule may be a sign of thyroid cancer

C.

Hypothyroidism  Know the consequences of untreated hypothyroidism in the neonate  Recognize the signs and symptoms of hypothyroidism  Know how to use laboratory tests effectively to diagnose hypothyroidism  Know the varying causes of hypothyroidism

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 Know how to manage and treat hypothyroidism and the use of TSH to guide the treatment  Know the prognosis for a patient with hypothyroidism  Know how to recognize thyroid-binding globulin deficiency D.

Hyperthyroidism  Be aware of various treatment modalities for hyperthyroidism and complications of treatment  Recognize the signs and symptoms of a thyroid storm and treatment  Recognize the signs and symptoms of neonatal hyperthyroidism

IV.

PARATHYROID DISORDERS Goal: Understand the role of parathyroid hormone in calcium, phosphorus and skeletal homeostasis  Recognize the typical laboratory findings associated with hypoparathyroidism  Know how to recognize a child with pseudohypoparathyroidism  Know that DiGeorge syndrome (22q-) can be a cause of hypoparathyroidism  Know that hyperparathyroidism is common in patients with chronic renal insufficiency  Identify the most common laboratory findings in parathyroid dysfunction

V.

ADRENAL GLAND DISORDERS (I.E. ADDISON DISEASE) Goal: Identify patients with cortisol deficiency and management of adrenal crisis  Recognize the signs and symptoms of Addison disease  Know how to use laboratory tests effectively for the diagnosis of Addison disease  Plan the treatment of an adrenal crisis in a patient with Addison disease  Know the causes of Addison disease and related disorders  Recognize that Addison disease is an autoimmune disorder  Be aware of adrenoleukodystrophy  Congenital adrenal hyperplasia (see section of disorders of sexual differentiation/ambiguous genitalia)

VI.

TYPE 1 DIABETES MELLITUS Goal: Identification, diagnosis and treatment of uncomplicated and complicated type 1 and type 2 Diabetes Mellitus Page 7 of 11

A. General  Recognize the signs and symptoms of type 1 diabetes  Know how to treat type 1 diabetes effectively to achieve good control: insulin, diet, exercise  Know how to treat type 1 diabetes effectively to achieve good control: insulin, diet, exercise and psychological acceptance of the disease  Know the value of hemoglobin A1c in the management of type 1 diabetes  Know the natural history of type 1 diabetes  Counsel patients on the self-management of type 1 diabetes  Differentiate between the Somogyi and Dawn phenomena  Know how to manage sick days in diabetic patients  Know the long term complications of type 1 diabetes  Know the importance of blood glucose control in the prevention of long-term complications of type 1 diabetes  Recognize the association between type 1 diabetes and other autoimmune disorders  Know the treatment modalities used in type 1 diabetes (i.e. subcutaneous injections, insulin pumps, glucose sensors) B. Diabetes Ketoacidosis (DKA)  Know the complications of type 1 diabetes, particularly DKA and its pathophysiology, treatment and complications (hypokalemia, hypoglycemia, cerebral edema, shock)  Recognize cerebral edema as a complication of the treatment of diabetic ketoacidosis  Understand the risks of using bicarbonate in diabetic ketoacidosis  Understand how noncompliance plays a role in recurrent DKA VII.

TYPE 2 DIABETES (NONINSULIN-DEPENDENT DIABETES MELLITUS)  Understand the difference between type 1 diabetes and type 2 diabetes  Know that acanthosis nigricans is a marker for insulin resistance  Understand the treatment approaches to type 2 diabetes  Understand that etiology of obesity is multifactorial Page 8 of 11

 Know the genetic conditions that are responsible for obesity in children  Know that nutritional support, behavior modification and exercise are essential components in the treatment plan for obesity  Know the etiology of hypoglycemia during the newborn period VIII.

DISORDERS OF CALCIUM AND PHOSPHATE METABOLISM Goal: Identify the most common causes of calcium and phosphate metabolism at different age groups, signs, symptoms, laboratory work-up and appropriate treatment A. Hypocalcemia  Recognize the signs and symptoms of hypocalcemia  Know the causes of hypocalcemia in a neonate  Know the hypocalcemia with hypophosphatemia suggests vitamin D deficiency  Know that hypocalcemia with hyperphosphatemia suggests hypoparathyroidism B. Hypercalcemia  Recognize the signs and symptoms of hypercalcemia  Recognize the possibility of hypercalcemia and its complications following prolonged immobilization C. Hypophosphatemia  Recognize the typical clinical and laboratory findings associated with familial hypophosphatemic rickets  Plan the treatment of a child with familial hypophosphatemic rickets

IX.

SEX DIFFERENTIANTION Goal: Understand the role of the pediatrician in recognizing normal vs. abnormal anatomy of the external genitalia, identification of most common causes of ambiguity, diagnosis, genetic and/or molecular basis and treatment. A. Normal development  Know the normal anatomy of the genitalia and its development  Understand the effect of androgens on the formation of the external genitalia  Understand the effect of müllerian-inhibiting factor on the internal duct structure B. Ambiguous genitalia  Recognize the signs and symptoms of congenital adrenal hyperplasia (CAH) Page 9 of 11

 Know the laboratory evaluation of CAH  Know that CAH can be diagnosed prenatally  Plan the treatment for an adrenal crisis in a patient with CAH  Understand the value of neonatal screening for salt-losing CAH in male infants  Recognize the signs and symptoms of male pseudohermaphroditism (46, XY with testes)  Understand that maternal exposure to androgens or progestins can cause virilization in female infants X.

HEALTH MAINTENANCE AND PREVENTION IN ENDOCRINOLOGY The role of the pediatrician in identifying individuals at risk for the development of endocrine dysfunction.  Know how to interpret the newborn screen (example, congenital hypothyroidism, congenital adrenal hyperplasia, galactosemia)  Early identification of growth acceleration or deceleration as seen in growth hormone deficiency or acromegaly  Know the importance of vitamin D supplements in breast-fed infants and select populations with low intake of vitamin D, calcium or phosphorus  Diabetic screening for patients with polyuria, polydipsia, polyphagia, recent and unexplained weight loss, acanthosis nigricans  Obese children should be screened for dysmetabolic syndrome (obesity, insulin resistance, diabetes, hypertension, lipid dysfunction)  Understand that treatment for obesity includes an appropriate nutrition, behavioral modification and exercise  The association of chronic steroid use and decreased bone mineral density  The common symptoms associated with the abuse of anabolic steroids  The need for influenza vaccination in children with certain endocrine disorders (CAH, diabetes mellitus, hypopituitarism, Cushing syndrome)  The importance of diabetes control for prevention of long-term complications such as retinopathy, neuropathy, nephropathy, vascular insufficiency and gastroparesis

XI.

DIAGNOSTIC AND SCREENING PROCEDURES Goal: The role of the pediatrician using tools to identify endocrine dysfunction, interpretation and referral to endocrinologist if necessary  Proper use of growth, length, weight and BMI charts

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 Use of orchidometer in the assessment of sexual development  Use of staidiometer for accurate height measurement  Interpretation of bone age and DXA scans Resources: Kittredge, D., Baldwin, C. D., Bar-on, M. E., Beach, P. S., Trimm, R. F. (Eds.). (2004). APA Educational Guidelines for Pediatric Residency. Ambulatory Pediatric Association Website. Available online: www.ambpeds.org/egweb. th

th

Essentials of Pediatrics, 5 edition. Nelson Textbook of Pediatrics, 18 edition. Nelson PREP: self-assessment Q&A from Pediatrics Review and Education Program, section Endocrinology and Metabolism. General Pediatrics Outline Contents/Certifying Examination. Available online: www.abp.org/certinfo/genpeds/gpoutline.pdf rd

Textbook of Pediatric Endocrinology, Sperling 3 edition. Textbook of Pediatric th Endocrinology, Lifshitz, 4 edition

Revised 4/8/11

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