Patient Presentation
A 12-year-old female came to clinic for health supervision. Her mother had concerns that she was obese, hypothyroid and was more tired over the past few months. Her mother was well versed in dietary interventions and said that she kept a strict watch on the amount and type of food including specifically measuring out quantities. The patient drank water and skim milk. Her mother also said that she was compliant with her levothyroxine. She was not active in general but had been more tired that usual and got tired with regular activities. She was doing well in school and had good social interactions with her family and peers despite recently moving to the area. Previous records were unavailable. The past medical history showed her hypothyroidism was noted 3 years previously and no changes in the levothyroxine had been made since then. The family history showed parents, 2 siblings, and other family members with obesity and dyslipidemias. There was no diabetes, stroke or early cardiovascular deaths. The father was on lipid-lowering medication. The review of systems was negative.

The pertinent physical exam showed an obese female with BMI of 29.9 (>>95%), blood pressure of 103/68 and the rest of her vital signs were normal. HEENT showed normal thyroid without masses and a Tanner stage 3 female. Skin examination showed multiple striae but no acanthosis nigracans. The laboratory evaluation showed a TSH of 11.03 microunits/dL and T4 of 1.34 micrograms/dL. On a non-fasting sample cholesterol was 193 mg/dl (75-90%), triglycerides 208 mg/dl (>>>95%), HDL of 55 mg/dl (>50%) and LDL of 94 mg/dl (50%). Her glucose, hemoglobin A1c, renal and liver function tests were normal. The diagnosis of obesity, undertreated hypothyroidism and hypertriglyceridemia was made. The patient’s levothyroxine was increased with followup in a few weeks. It was hoped that as her hypothyroidism was better treated that she would have more energy and would be able to start a more regular exercise program. Fasting cholesterol and triglycerides were to be repeated soon. The patient was also going to try to eat more fruits and vegetables and start some soluble fiber. A multidisciplinary clinic with endocrinology, cardiology and dietary services was available for additional help with managing obesity and dyslipidemias. The family was referred as cholesterol subtypes testing was not available, the patient may need pharmacological treatment, and education for the entire family was felt to be beneficial. The mother was also going to obtain previous records for the entire family.

Discussion
Research has supported the idea of childhood precursors to adult disease including obesity and for cardiovascular disease. Cardiovascular disease is the leading cause of morbidity and death in the United States and dyslipidemias are one risk cardiovascular disease. Dyslipidemias do occur in childhood. Despite much research, there is still more that remains to determine the exact laboratory cut off numbers for various treatments and the best pharmacological treatments for patients that might benefit from them.

The American Academy of Pediatrics (AAP) recommends that all children eat a healthy diet, and for those with risk factors (i.e. family history of hyperlipidemia, premature cardiovascular disease, obesity, hypertension, diabetes mellitus, cigarette smoking or an unknown family history) a fasting lipid screening panel is recommended after the age of 2 and not later than 10 years of age. For those that have normal testing, rescreening every 3-5 years is then recommended.

Learning Point
The AAP recommends dietary and lifestyle interventions for children with dyslipidemias. They also offer recommendations for treatment with pharmacological interventions for children with elevated LDL.

• For children less than 8 years old, diet and exercise are the usual treatment. Pharmacological interventions are recommended for this age group only if there is “…dramatic elevation of the LDL concentration (>500 mg/dL) as seen with the homozygous form of familial hypercholesterolemia.”
• For children more than 8 years old, pharmacological interventions are recommended using a graduated LDL the cut off. Implementation depends on risk factors. Children with no risk factors but LDL > 190 mg/dL despite diet therapy should be considered.
• Child with risk factors including “obesity, hypertension, cigarette smoking or positive family history of premature cardiovascular disease should be consider with the LDL is persistently > 160 mg/dL despite diet therapy.
  For children with diabetes, pharmacological treatment should be considered when LDL concentration is > 130 mg/dL.

The goal is to lower the LDL to less than 130 mg/dL or even 110 mg/dL in patients with risk factors.

Recommendations from a lipid disorders clinic in Canada notes, “Because of the scarcity of data on the safety and efficacy of lipid-lowering medications for children and adolescents, pediatric lipid disorder specialists might be consulted before medication administration is initiated.” Because there is little to no pediatric data, their recommendations are extrapolated from adult data. These authors, like the AAP, recommend first and foremost, dietary and exercise changes along with smoking and alcohol cessation, along with treatment of underlying disorders such as diabetes and hypothyroidism.

• For triglycerides > 130-445 mg/dL, they recommend lifestyle modifications and ω-3 fatty acids. Depending on the response, then statins are considered.
• For triglycerides > 445-900 mg/dL, they again recommend lifestyle modifications and ω-3 fatty acids to start. Depending on the response statins and fibrates are considered.
• For triglycerides > 900 mg/dL, referral to a lipid disorder clinic is recommended with treatment by ω-3 fatty acids, statins and fibrates as appropriate.

Questions for Further Discussion
1. What are the different categories of dyslipidemias?
2. What referral resources are available in your local area for dyslipidemia?
3. What screening laboratory tests are recommended for obese patients?
4. What is the definition of metabolic syndrome for adults and children?

Related Cases

Disease: Obesity in Children | Thyroid Diseases | Triglycerides

Symptom/Presentation: Abnormal Laboratory Test | Obesity

Specialty: Cardiology / Cardiovascular-Thoracic Surgery | Endocrinology | General Pediatrics

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Obesity, Thyroid Diseases, and Triglycerides

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Daniels SR, Greer FR; Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008 Jul;122(1):198-208.

Manlhiot C, Larsson P, Gurofsky RC, Smith RW, Fillingham C, Clarizia NA, Chahal N, Clarke JT, McCrindle BW. Spectrum and management of hypertriglyceridemia among children in clinical practice. Pediatrics. 2009 Feb;123(2):458-65.

ACGME Competencies Highlighted by Case

Patient Presentation
A 10-year-old male came to the emergency room 24 hours after getting his thumb caught in another player’s football helmet. It was painful and swollen, despite some ice treatment. He was otherwise well. The pertinent physical exam showed a healthy boy whose dominant right thumb was swollen at the thenar eminance without bruising. The thumb was not in an abnormal position. He was able to move all the thumb joints but had pain especially with flexion. There was no pain in the anatomic snuff box and his sensation was intact. There was no laceration and the other fingers and rest of the hand was normal. \The diagnosis of a soft tissue injury after trauma was made. Because of the location, a splint was placed for comfort and protection from additional injury. The family was advised to take the splint off and gently move the thumb. Ice and elevation was also recommended. The family was to return to their regular physician if symptoms worsened or did not seem to be improving in 3-5 days.

Discussion
The thumb has two phalanges anda metacarpal and articulates with the trapezium bone in the wrist. It gives humans prehensile abilities. Children can be difficult to examine because of their developmental age including non-compliance, fear and ability to understand. Pain also does not help the examination. Pain, decreased range of motion and swelling along with abnormal position may indicate a fracture or dislocation. Crepitus and abnormal skin findings such as dimpling, and a filled in normal crease may indicate a more serious problem.

Almost all injuries are treatable by immobilization and as necessary surgical treatment with open reduction and possible fixation. If there is doubt about the treatment, a referral should be made to the appropriate local resource such as an orthopaedic or hand surgeon. Outcomes are related to the amount of energy causing the injury. Low energy usually has very good outcomes, while higher energy is more variable because there often is more extensive damage including the physis and intraarticular surfaces. Complications include loss of motion because of immobilization (usually amenable to range-of-motion exercise), decreased function, stiffness and/or degenerative posttraumatic arthritis.

Learning Point
Fractures
Distal phalanx injures are often crush injuries. If it is only the distal phalanx that is fractured, then repair of any laceration with careful attention to nailbed repair if needed usually gives appropriate realignment of the fracture. A transverse distal phalanx injury may be unstable and require surgical treatment.

Hyperflexion injuries can cause Salter-Harris fractures. Salter-Harris fractures, especially type I and II often found in children, can often be treated with splinting if the displacement and angulation are small. Displaced physeal injuries should be referred. Salter-Harris fracture type III is more common in adolescents and may require surgical treatment with open reduction and fixation.

Proximal phalanx fractures often angulate and may rotate because of the phalanx’s intrinsic muscles. If the displacement and angulation are minimal then splinting with followup in 3-5 days is usually appropriate. If there are concerns about the angulation or displacement then the patient should be referred.

Mallet thumb (mallet finger is sometimes called baseball finger) is caused when the extensor tendon is injured. It is usually treated with splinting for several weeks.

Gamekeeper or skier’s thumb (caused by falling onto ski poles) is an avulsion of the ulnar collateral ligament of the proximal phalanx. Falling onto bike handlebars is also a common cause. This is usually treated with casting but may require surgery.

Thumb metacarpal fractures of the neck or shaft usually are treated like other phalanx injuries. Metacarpal base fractures often require surgical fixation because of the physis and/or intraarticular involvement.

Disclocations
Dislocations are often hyperextension injuries. The proximal interphalangeal joint is usually easily reduced. Metacarpal-phalangeal dislocations are more difficult and may require surgical reduction. Any dislocation that appears to be unstable after more conservative treatment may require surgical treatment. Surgical treatment is usually indicated if there is a dislocation that is not reducible, or the joint is unstable after relocation, or if there is an open injury or a chronic dislocation.

Questions for Further Discussion
1. What are indications for radiographs of the hand?
2. Why is the vaccination history important for a child with a hand injury?

Related Cases

Disease: Finger Injuries and Disorders

Symptom/Presentation: Upper Extremity Trauma

Specialty: Emergency Medicine | Orthopaedic Surgery and Sports Medicine

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Finger Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:681-682.

Kozin SH. Fractures and dislocations along the pediatric thumb ray. Hand Clin. 2006 Feb;22(1):19-29.

Laub DR, Priano SV. Thumb Fractures and Dislocations. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/1287814-overview (rev. 9/7/2010, cited 10/4/2011).

ACGME Competencies Highlighted by Case

Patient Presentation
A 3-year-old male and 4 year-old female came to a pediatric emergency room. At triage the mother was noted to be quite agitated. She refused to sit, rocked back and forth and was talking under her breath. Her answers didn’t make sense to the nurse, who became concerned about the mother and quickly moved the family into a room. The nurse called the senior resident who went to see the family right away. When the resident entered the room, the mother was standing against the wall and would rock or walk in small circles. The mother would answer questions briefly about the children, and then seemed to be carrying on a conversation with herself but specifics couldn’t be heard. When asked if she was feeling well, she became even more agitated. She said she wanted medicine for the children’s colds. The resident tried to ask again and the mother started move toward the resident in a threatening manner and then turned away. The children appeared well with rhinorrhea present and the mother was not being threatening towards them, so the resident left the room with the door open and quickly talked with the attending physician. Together the attending and resident went to see the family. The attending physician asked her again if she felt well and the mother became more agitated verbally. When asked if she had any medical problems or had taken any medications the mother denied it. She also denied any alcohol or drugs. It became clearer listening to the mother that she was talking to someone who was not present. When asked, the mother said that she was hearing a voice talking to her who was “making her angry” when she just wanted medicine for the children. She denied visual hallucinations. Initially the mother refused to have the children examined, but after some more talking, allowed the resident to do a screening examination. They had upper respiratory infections. Meanwhile the attending was arranging transfer to an adult emergency department which had emergency psychiatric consultation and facilities and the Department of Social Services. The attending also contacted family members that the mother wanted called. A psychiatric nurse and a plain-clothes security officer were called to the emergency department but were kept out of sight because of the risk of aggitating the mother. The triage nurse brought food and drink for the family but the mother lunged for it and threw it in the sink and garbage can saying that it was poisoned. The resident developed some rapport and was able to calm her down by taking the food away and staying in the room talking with her. The mother agreed to go in the ambulance with the children and the staff felt this was appropriate as she previously became threatening when attempts had been made to separate the children from her (i.e. taking them to the bathroom). It was also decided that the resident would also go because her presence seemed to have a calming effect on the mother and she could monitor the children. The plain-clothes security officer also went in the ambulance. The transfer was uneventful and the mother was admitted with the diagnosis of acute psychosis. Social services and family members who met at the adult emergency department arranged to place the children with the family members.

Discussion
Workplace violence is defined by the Occupational Health and Safety Administration (OSHA) as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.” Social services and health care professionals are at high risk for workplace violence, with the numbers probably higher because of underreporting. In 2000 the Bureau of Labor statistics reported the following rates of injuries from violent acts and assaults. Rates are per 10,000 full-time workers

Overall private sector	 	2
Health services 			9.3
Social services 			15
Personal care facility 		25

The Department of Justice has average annual rates of non-fatal violent crime from 1993-1999. Rates are per 1000 workers

All occupations 		12.6
Physicians 			16.2
Nurses				21.9
Mental health professionals 68.2

OSHA lists several reasons for the increased risk including:

• "Health care and social service workers face an increased risk of work-related assaults stemming from several factors. These include:
• The prevalence of handguns and other weapons among patients, their families or friends;
• The increasing use of hospitals by police and the criminal justice system for criminal holds and the care of acutely disturbed, violent individuals;
• The increasing number of acute and chronic mentally ill patients being released from hospitals without follow-up care (these patients have the right to refuse medicine and can no longer be hospitalized involuntarily unless they pose an immediate threat to themselves or others);
• The availability of drugs or money at hospitals, clinics and pharmacies, making them likely robbery targets;
• Factors such as the unrestricted movement of the public in clinics and hospitals and long waits in emergency or clinic areas that lead to client frustration over an inability to obtain needed services promptly;
• The increasing presence of gang members, drug or alcohol abusers, trauma patients or distraught family members;
• Low staffing levels during times of increased activity such as mealtimes, visiting times and when staff are transporting patients;
• Isolated work with clients during examinations or treatment;
• Solo work, often in remote locations with no backup or way to get assistance, such as communication devices or alarm systems (this is particularly true in high-crime settings);
• Lack of staff training in recognizing and managing escalating hostile and assaultive behavior; and
• Poorly lit parking areas."

Learning Point
An impaired parent may be a potential threat not only to healthcare workers in the location, but also their children, the public and themselves.
An American Academy of Pediatrics clinical report outlines legal and ethical considerations when dealing with parents whose judgment is impaired by alcohol or drugs and also notes that they should be applicable for impairment due to any cause.

The report notes that there are several legal considerations which can be in conflict including:

• "the physican-patient relationship;
• the duty to act in the best interest and for the safety of the patient;
• the need to obtain informed consent;
• the importance of safeguarding patient confidentiality;
• the mandated reporting of suspected child abuse and neglect; and
• the duty as an employer and business owner to protect the safety of employees and visitors in the office."

A physician's first duty is to the patient and he/she should try to "...decrease the risk[s] by the least restrictive means[,]" attempting to deescalate the situation. This can be accomplished in several ways including moving the parent with or without the children to a private area as quickly as possible, talking with the parent, talking with other family members, obtaining alternative transportation such as a taxi, etc.. It may also mean utilizing child protection or law enforcement services as necessary to secure the safety of the children, health care professionals and the public.

Parents have a reasonable right to expect confidentiality but ensuring safety of people takes precedent over parent confidentiality (i.e. keeping a door open during discussions, separating the children from the parent, etc.) Health care providers must also act within the state laws for protection of children from suspected abuse and neglect and therefore with an impaired adult, child protection services usually is involved in some manner. An impaired parent is often not able to give treatment consent for their minor child, therefore non-emergent treatment usually is postponed until appropriate consent can be obtained. In the emergency room, the Emergency Medical Treatment and Active Labor Act (EMTALA) may require screening for emergency medical conditions and provision of treatment regardless of consent.

Overall, the case above was generally successful. The professionals attempted to deescalate the situation by recognizing it, moving the family to a room quickly, providing comfort items (i.e. food), and treating the family by a small number of professionals including having the resident assist in the transport. The professionals also tried to keep the door closed when possible for privacy and confidentiality but also balanced this against having the door open to monitor the mother and protect the children and health care professionals. Permission was obtained to contact family members, but social services was contacted without permission. The children were appropriately screened for an emergency condition in the pediatric emergency room. Had the professionals not been able to convince the mother to voluntarily transfer to the adult hospital, law enforcement may have been needed to protect the children and public.

Questions for Further Discussion
1. What are your procedures for an impaired parent situation?
2. What are your procedures for a workplace violence situation?

Related Cases

Disease: Psychotic Disorders | Medical Ethics

Symptom/Presentation: Hallucinations | Rhinitis

Specialty: Emergency Medicine | Medical Ethics | Psychiatry and Psychology

Age: Preschooler | Fetus and Mother

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Psychotic Disorders and Medical Ethics.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

U.S. Department of Labor Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for
Health Care & Social Service Workers
Available from the Internet at http://www.osha.gov/Publications/OSHA3148/osha3148.html (cited 9/30/11).

CDC/NIOSH. Violence. Occupational Hazards in Hospitals. 2002.

U.S. Department of Labor Occupational Safety and Health Administration. Workplace Violence Fact Sheet.
Available from the Internet at http://www.osha.gov/OshDoc/data_General_Facts/factsheet-workplace-violence.pdf (rev. 2002, cited 9/30/11).

Fraser JJ, McAbee GN, and Committee on Medical Liability, American Academy of Pediatrics. Dealing with the parent whose judgment is impaired by alcohol or drugs: legal and ethical considerations. Pediatrics. 2004:114;869-873.

ACGME Competencies Highlighted by Case

Patient Presentation
A resident was seeing children in his continuity clinic. He had noticed that several of his patients had failed newborn hearing screenings at birth, but were normal when repeated a couple weeks later. He asked how good the testing was. His attending said she didn’t know the exact numbers but that universal screening had been occurring for several years and “seemed to have pretty good results.” She also remarked that vision was to also be screened but again she couldn’t give any specific numbers. The attending told the resident that in addition to observing the child for any vision or hearing problems, and specific screening, she always tried to ask the family if they or anyone else had any concerns about hearing or vision and always would refer if anyone had any concerns. She said, “I know that it is not the best test, but a positive answer means the child needs further testing.”

Discussion
Sensory problems in children like any problem should try to be identified as early as possible so effective treatment plans can be carried out.

Hearing
About 1-4 children/1000 newborn infants have hearing loss or about 8-16,000 infants/year in the US. Before universal hearing screening the average age for detection was 2 1/2 -3 years of age.

In 2010, an evaluation of the universal newborn hearing screening programs found that about 92% of infants were screened before discharge with 4% failing the before discharge screening. Unfortanately only 2% were referred for a diagnostic evaluation. The authors cite multiple barriers to universal screening and followup. Types of hearing testing for screening includes evolked otoacoustic emission testing, auditory brainstem response or both.

Vision
Amblyopia is a “functional reduction in visual acuity characterized by abnormal processing of visual images, which is established by the brain during a critical period of vision development.” Strabismus is the most common cause of amblyopia and is an ocular misalignment. Asigmatism or blurred vision at any distance, hyperopia or farsightedness, and anisometropia or an asymmetric refractive error between the eyes, are also risk factors for amblyopia. 2-5% of preschool children have amblyopia. Highly effective treatment includes eyeglasses, patching and cycloplegic medications. Common standard tests are the HOTV visual acuity test, Random Dot E steroacuity test, cover-uncover visual alignment test, and fundus red reflex testing. Photoscreening, which detects ocular alignment and refractive blurring, and autorefraction techniques which automatically screens for refractive error are also commonly used.

Learning Point
Hearing
In one study of 300 infants, a sensitivity of 100% and specificity of 99.7% was achieved with an overall referral rate of 2.0% was found hearing screening. The states of Colorado, Mississippi, Rhode Island, and Texas have reported referral rates of 3-10% and a false positive rates of 3.6%. These are well around the NIH guidelines for hearing screening programs of failure rates of 5-7%.

Vision
The US Preventive Services Task Force (USPSTF) found that of the studies they evaluated “… none of the tests was associated consistently with both high sensitivity and high specificity (ie, > 90%) for specific amblyogenic risk factors.” The testing included visual acuity, steroacuity, ocular alignment, photoscreening and autorefractors. The USPSTF recommends screening at 3-5 years but says there is insufficient evidence before age 3 for universal screening . In the USPSTF statement the tests evaluated included HOTV, Random Dot E, cover-uncover, photoscreening, and autorefraction techniques.

The Children’s Eye Foundation cites photoscreening and autorefraction studies with generally high rates of being able to do the screening (97-99% screenability) with sensitivities in the 45-70% range with a specificity of ~98%. Referral rates were 5-10% for further studies.

Some authors critical of the omission of the USPSTF screening recommendations for screening in children < 3 years of age, point out that fundus red reflex examination is a standard screening test that can help to detect congenital cataracts, other causes of deprivation amblyopia, and retinoblastoma. They go on to point out some newer studies demonstrate good positive predictive values and urge use of photoscreening and autorefraction in < 3 year olds. One study they cite showed photoscreening to have higher positive predictive values in 3-4 year old children than testing with HOTV monoular distance acuity testing and Random Dot E testing for steopsis.

Questions for Further Discussion
1. What type of hearing screening are performed at your local institutions?
2. What is your hearing screening failure rate?
3. What visual screening tests do you perform and at what ages?
4. What is your referral rate for failed visual screening?

Related Cases

Disease: Health Screening | Vision Impairment and Blindness | Hearing Problems in Children | Newborn Screening

Symptom/Presentation: Abnormal Laboratory Test | Health Maintenance and Disease Prevention | Hearing Problem

Specialty: Ophthalmology | Otolaryngology

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Health Screening, Vision Impairment and Blindness and Hearing Problems in Children.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Schmidt P, Baumritter A, Ciner E, Cyert L, Dobson V, Haas B, Kulp MT, Maguire M, Moore B, Orel-Bixler D, Quinn G, Redford M, Schultz J, Ying GS. Predictive value of photoscreening and traditional screening of preschool children. J AAPOS. 2006 Aug;10(4):377-8; author reply 378-9.

Shulman S, Besculides M, Saltzman A, Ireys H, White KR, Forsman I. Evaluation of the universal newborn hearing screening and intervention program. Pediatrics. 2010 Aug;126 Suppl 1:S19-27.

Delaney, AM, Meyers AD. Newborn Hearing Screening. Medscape.
Available from the Internet at http://emedicine.medscape.com/article/836646-overview#a1 (rev. 06/15/2010, cited 9/26/2011).

US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics. 2011 Feb;127(2):340-6.

Donahue SP, Ruben JB; American Academy of Ophthalmology; American Academy of Pediatrics, Ophthalmology Section; American Association for Pediatric Ophthalmology and Strabismus; Children’s Eye Foundation; American Association of Certified Orthoptists. Pediatrics. 2011 Mar;127(3):569-70.

Children’s Eye Foundation. Types of Vision Screening Devices.

Available from the Internet at http://www.childrenseyefoundation.org/index.php/Programs/types-of-vision-screening-devices and http://www.childrenseyefoundation.org/index.php/Programs/types-of-vision-screening-devices-continued (rev. 2011, cited 9/26/2011).

ACGME Competencies Highlighted by Case