Clerkship Program - Clinical Activities
- Goals & Objectives
- Academic Activities
- Clinical Activities
- Policies & Procedures
- Influenza Case Study
- Meeting the Challenges of Caring for the Underserved
This is the most important part of your pediatric rotation. This is where you develop your skills in assessing pediatric patients and in clinical decision making. It can be extremely rewarding and is an invaluable experience.
- Clinical Responsibilities
- Examining Patients
- Procedures
- Interpersonal Skills
- Format for Notes
- Writing Orders
- Presentations on Rounds
Clinical Responsibilities
Outpatient Clinic Responsibilities
These will be explained to you in detail when you arrive at your clinical site. In brief, your responsibilities will vary with the specific clinic (General Pediatrics Teenage, Cardiology, Neurology, etc.). At times you will see patients on your own and be “staffed” by a clinic attending physician. At other times you will accompany a resident or attending in seeing patients and your role will be more observational. Ask questions, examine patients and seek assistance with history taking and physical exam skills. You should take as active a role as possible, knowing that good patient care must coexist with, and at times take precedence over, a clinic’s teaching function. You are encouraged to assist in clinic charting. Those who make the most out of it get the most out of it. Don’t be afraid to ask questions of residents and staff. Be involved!
When you are assigned to a continuity clinic, you will work with a staff person and one or two residents who are seeing their patients in continuity. The M3 may work with a resident or may work up a patient alone and then present that patient to the staff person. If you are assigned to a faculty clinic, you will likely be working one-on-one with a faculty member. In urgent care clinic, you will work with a faculty member and possibly a resident, seeing patients with acute care needs whose primary care providers are not available.
Patients Present to These Clinics for Several Basic Types of Visits
- Health supervision (HS)—well-child, health-maintenance visit. There are preprinted forms for planned HS visits to serve as guides for eliciting and recording the various aspects of the visit. A supplemental handbook is available in the conference and patient rooms.
- Simple problem visit. These may be short follow-up visits for assessment of acute problems. Depending on the problem, the work-up is much more focused or directed than a hospital or HS work-up.
- Complex problem visits. These are scheduled for longer intervals to allow sufficient time to address chronic, complex or multiple problems. Here the work-up is tailored to the problem, but may resemble the complete H & P.
Tips Regarding Working in the Clinic
- Before going to see the patient, take a minute to review the problem, medication and immunization lists as well as phone or clinic notes preceding the current visit. These may contain helpful information that the patient assumes you know. Or you might pick up a child who needs to catch up on shots. Try to generate an initial differential diagnosis before entering the room, as this may help you ask more pertinent questions in your history.
- Patients to be seen are noted on the clipboards in the conference rooms. If you see a patient, put your initials next to the patient’s room number on the clipboard. Put the blue student/resident flag outside the room. As you leave the room, don’t forget to replace the flag. When the patient has been discharged, cross the name off the board and be sure the red flag indicating the room is in use has been replaced.
- If a culture has been done, the appropriate tracking slip must be filled out. It is important to confirm a phone number where a responsible person can be reached with positive culture results. Also note the pharmacy the family wishes to use if medications need to be called in.
- If the M3 does the work-up, a write-up is expected. The form will serve as a recording instrument for most HS visits. If problems are identified for which the form is not adequate, a clinic note sheet is added to allow recording of the problem, assessment and plan. For most simple problem visits a short (one page maximum) SOAP note is written. For longer problem visits, always note who referred the patient. Always sign the write-up. The attending staff will review, add comments and cosign the write-up.
Specialty Clinics
Specialty clinics (e.g., cardiology, GI, endocrinology) consist of a variety of experiences that will expose you to many children with positive physical findings and show that a large part of continuing care for major illness can be done on an outpatient basis with a team effort.
Inpatient Responsibilities
Philosophy of the Ward Team
The key point is to remember that you are a welcome member of the medical “ward team,” made up of a pediatric senior resident (PL-3—the team leader), interns (PL-1s), subinterns (Med 4s) and two to four Med 3s (that’s you!) under the guidance of the general team attending physician. The “medical” ward team interacts with nurses, nursing students, pharmacists, pharmacy students, respiratory therapists, social workers, etc.—all comprising the greater ward team. The ward team also interacts with the team members from various pediatric subspecialty services, surgical services, etc.
All the work you do as part of the ward team is designed to accomplish the dual functions of teaching and good patient care. The ultimate focus of both your individual and ward team efforts is the patient, both present (through service functions) and future (through learning functions).
Specific Med III Ward Responsibilities
Working-Up Patients
- You are responsible for doing a complete work-up on one new patient each weekday (M–F). PICU transfers or postoperative patients can be used for this as long as you talk with the patient and family to obtain all the relevant admission information.
- The pediatric senior resident will use his or her discretion to choose which patients Med 3s should work up, in order to provide better experience, variety or workload distribution among ward team members. (Med 3s should feel free to convey special interests to the senior resident.)
- A complete work-up includes a complete history and physical exam, as well as an assessment including a differential diagnosis and a plan listing recommendations for diagnostic studies and treatments.
- Work-ups should be on the chart the day the patient is admitted to the hospital.
- All write-ups should be read and countersigned by your senior resident, intern or attending.
Picking Up Patients
- You will also be assigned to follow patients whom you did not work up (e.g., admitted by on-call team, in hospital when you arrived, transferred from PICU, etc.).
- You will not be asked to write up more than one patient a day (except on rare occasions, at the discretion of your PL-3), unless on call that night. However, you may at times be involved in the history and physical exam of more than one patient per day. You need not write these patients up, but would usually “pick them up” to follow. In essence, you would be able to learn from participating in the history and physical but could avoid some paperwork responsibilities. This often comes up in the case of multiple admissions on night call, especially when the patient is admitted to the opposite ward from where you are based.
Following Patients
- You are encouraged to take an active role in the care of your patients, acting as much like a subintern as possible (gaining experience in writing orders, having input on the diagnostic and treatment plans, etc.).
- Generally, Med 3s will follow three to four patients at a time. The actual number may vary based on the census of the ward.
- No Med 3 should write orders without first discussing them with house staff or a subintern.
- ALL MED 3 ORDERS MUST BE COSIGNED BY HOUSE STAFF.
- You are responsible for daily progress notes on all patients you are following.
- You should be familiar with your patients’ problems, on at least a basic textbook level of knowledge.
- You should plan to present your patients on rounds daily.
- You should be aware of all pertinent data on your patients each day. This includes subjective data from patient and family, nursing observations, physical exam, labs, x-rays and other diagnostic tests. All pertinent data should be entered into the daily progress note.
Ward Call
- The primary contact person for the Med 3 on call is the intern. You should accompany him or her in assessing problems that come up, working up admissions, gathering lab and other patient data, assisting in procedures, etc. At times the senior resident on call may ask the Med 3 to accompany him or her to see an interesting patient in the PICU or ER for learning purposes only (i.e., no paperwork).
- The interns, subinterns and senior residents on call with you may not be members of your usual ward team. They have the same authority and responsibilities as your usual team, however. This mixing is intentional to give you exposure to multiple resident personalities and styles.
- In the past many Med 3s have described their on-call experiences as some of the best of their rotation. Others have had uneventful nights on call, making them question the usefulness of Med 3 call. I feel the experience is generally a good one, but I am fully aware that the experience is variable.
The Ward Routine (a rough outline)
- SEE PATIENTS/GATHER DATA—This occurs before work rounds each weekday and before sign-outs on Saturday and Sunday. Usually, this means you must arrive on the ward sometime between 7:00 and 7:30 AM, depending on your patient load.
- WORK ROUNDS—The start time varies with the ward census and the PL-3. Here is where the basics of patient management, as well as some teaching, are conducted. You should be prepared to present your patients each day. There are no formal work rounds on weekends.
- ATTENDING ROUNDS— (10:30–11:30 AM) - These are teaching rounds three to four days per week.
- NOON CONFERENCE—These for the most part begin at 12:00 noon and occur two to four days per week. Topics vary.
- ADMISSIONS/WARD WORK—Afternoons are basically left to patient work-ups and miscellaneous patient care. Depending on workload, your PL-3 may schedule some minilectures. (NOTE: On two afternoons you will be going to rounds either with your attending or with the chief resident.)
- SIGN-OUT ROUNDS (@ 4:30) —This is required only for those on call.
Examining Patients
Examining children and adolescents can be difficult for those not used to this task. Here are a few tips:
- OBSERVE others, modeling behavior you find effective.
- BE SENSITIVE to both patients and parents.
- TIMING of patient physical exam is important, especially with inpatients. While it is true that patients should be examined daily, it might be best to wait for the intern or senior to examine certain patients with you, both for help and to avoid unnecessarily disturbing the child (and also the parents and nursing staff!). This is especially important for:
- infants (who must be “settled”)
- patients in pain
- very sick or complicated patients
- patients eating a meal
- sleeping patients (unless you can examine without waking
Procedures
Students usually do not perform many procedures while on pediatrics for a number of reasons:
- Children are not usually the most appropriate to “learn on” because of both size and psychological development (both children and parents may have heightened anxiety with hospitalization).
- Pediatric house staff have a greater need to perfect their procedural skills, especially on younger patients.
- Adequate opportunity to learn skills exists on other adult Med 3 rotations.
- Many procedures (such as infant IVs, etc.) are unnecessary for most of you to learn unless you go into pediatrics, in which case you will have ample opportunity to learn.
There is no “rule,” however, that Med 3s cannot perform certain procedures under adequate supervision on the proper patient in the appropriate situation. Remember that much can be learned from observing and assisting in procedures performed by house staff. You are all encouraged to do this, especially for patients you follow. Ask questions about technique and pitfalls. The procedures on the pediatric wards and clinics consist mostly of IVs, Per-Q-Caths, Foleys, suturing, lumbar punctures, blood drawing, cerumen removals and dressing changes.
Interpersonal Skills
One of the challenges of pediatrics is to communicate adequately and correctly with patients of various ages, as well as with parents. Quite often, the patient is too young to give a history or even to cooperate with verbal physical exam cues.
It is good to remind yourself that crying, anger, fear or blatant lack of cooperation may be normal for the patient at that time and is therefore a sign of health in one respect. The way you approach this patient, your appearance and your verbal and nonverbal cues will mold the relationship you have with the patient and his or her parents.
Remember, the entire pediatric team is a resource for you. The pharmacists, social workers, unit clerks, respiratory therapists and, especially, nurses have a great deal of pediatric experience. Respect them. Your interpersonal skills in interacting with these fellow professionals are very important in both “surviving” and enjoying your rotation on pediatrics.
Format for Notes
Pediatric History and Physical (Admit Notes)
Referring PhysicianDate and Time
CC—In the words of the patient or parent, what problem brought him or her to the hospital.
HPI—Remember that good chronology is very important.
PMH—Pregnancy Hx (gravida, para, rubella and hepatitis immunity, maternal age and blood type, etc.).
Birth Hx (birth wt., # weeks gestation, APGARs, resuscitation needs)
Neonatal Hx (jaundice, ABO incompatibility, went home with mom on day two, etc.).
Medications /Illnesses /Hospitalizations /Surgeries /Allergies /Immunizations /Developmental Hx
- At what age did the patient coo, smile, roll over, sit, walk, talk—a few words and in sentences. See Harriet Lane handbook for appropriate ages.
- Is he or she able to do appropriate tasks? If they are not appropriate, consider developmental testing.
- Try to determine what areas are delayed (e.g., gross motor, language, fine motor or social) as well as when the delays began.
SCHOOL HX—(for older kids)—current grade level and school performance.
TRAVEL HX
DIET HX—Especially important to detail in kids under two years old and all patients with GI problems or failure to thrive.
- For infants, include formula type, breastfeeding, amount per day, frequency.
- Feeding problems, introduction of solids, spitting up, etc.
PT PROFILE—(Social History) —Remember to include parents’ occupations, environmental exposure, home setting, if in daycare, use of AOD for teens.
FH—Include a family tree when possible and pertinent positives and negatives about the family history.
ROS—Only on the three graded write-ups is it necessary to write out all the negatives, etc. On other H & Ps list pertinent positives and negatives only. Remember that this section is for those things that are unrelated or not commented on already in the HPI. You do not need to repeat. If it is pertinent to the HPI it should be listed there.
PE—Be sure to include height, weight, head circumference and percentiles for each from growth chart, along with vitals.
ASSESSMENT—Include Dx and treatment and laboratory test rationale. This is the most important section in which to demonstrate that you know your patient.
PLAN—Include specifics with medication dosages and routes of administration; IV rates, volumes and solutions; oxygen administration; and other treatments and testing procedures.
In the first two write-ups include a discussion, two to four paragraphs in length, regarding the patient’s problem and management plan. References should be included. (You need at least three current journal references for each submitted write-up.)
Daily Progress Notes
Try to complete notes as early as possible in the day so intern can review and sign them (ideally on chart by 3:00 PM or earlier). A good note is a BIG help to the interns who have to write notes on lots of patients.
All progress notes must be dated, timed and signed by you.
SOAP form—useful for most patients.
Systems approach for complicated patients (CNS, Resp, CV, FEN, Heme, ID, Social, Other), or use a problem list.
Post-op Check Notes
PT ID—___ y/o M/F underwent (name of procedure) today for (reason)
SIGNIFICANT PHM—(See preop H & P or ask parents)—try to include patient’s original presentation.
ALLERGIESPREOP MEDS
TYPE OF ANESTHESIA AND COMPLICATIONS (see OR record)
LENGTH OF PROCEDURE
INTRAOPERATIVE COMPLICATIONS (see surgeon’s note)
BLOOD LOSS
FLUID REPLACEMENT (blood, colloid, crystalloid, FFP, etc.)
- Be sure to include OR and recovery.
URINE OUTPUT
- Again, include OR and recovery, etc.
- Should be total as well as cc/kg/hr
CURRENT IV FLUID AND RATE
- Double-check rate to be sure it is appropriate (e.g., maintenance, twice maint., 2/3 maint., etc.).
LINES—PIVs or central lines
DRAINS—NG, Penrose, Foley, chest tube, etc.
MEDS—Check appropriate doses and list as mg/kg (patients frequently come back from the OR with inappropriate doses).
PE—Vitals taken when patient arrived back on ward (BP P R T Wt)
O2 requirement and pulse ox (if needed)
Exam of heart, lungs, abdomen, and any other pertinent exam
IMPRESSION—______y/o now postop from (procedure)
State how patient is doing and any intraoperative diagnoses. List problems that will need to be followed.
PLAN—List for each problem. Be sure to include medications, O2 needs, parameters to watch for, labs that need to be followed. Also include anything the surgeons may have overlooked or forgotten.
Writing Orders
You are encouraged to write the admit orders on patients you admit. Sometimes the intern will need to do them because of time constraints, but in those cases you should write your own set of orders and compare them to what was written, for practice. You should write the orders on your patients as discussed on rounds and have an intern or senior resident sign them immediately. Usually it is easiest to bring the order book on rounds and write orders as we discuss patients.
Admit to F6/4, F4/4—include attending physician, admission weight
Diagnosis
Condition (Use good, fair, poor—never use stable)
Vitals (q2, q4, q shift, etc.)
Allergies
Activity
Notables (Please do not write “nursing” in orders since they really do all the orders.) e.g., elevate head of bead, I & Os, daily weights, NG to suction, etc.
Diet
IV Fluids
Medications
Symptomatic or PRN medications
Extras—CR monitor, pulse ox., CPT, etc.
Presentations on Rounds
Presentations on rounds should be concise but thorough enough that the ward team has all the essential information from which to make management decisions. For new admissions, the presentations should be longer so that we know who the patient is, how he or she presented, etc. For uncomplicated patients who have been here for a while, a brief review is adequate. Presenting by systems or by problem helps to organize our thinking and may be necessary for complicated patients. We expect more thorough presentations during attending rounds.
New Admission
HPI—most detailed part of presentation
Significant PMH—Mention all major events (birth Hx, dev. Hx, immunizations, ROS–see pediatric H & P format); detail only if it is pertinent to the patient’s current problems.
Admitting meds and allergies
FH—if pertinent
PT profile
PE on admission—Always start with vitals and general appearance, then detail the significant findings (positive and negative on PE).
Course—since admission
Assessment—problem list and status of each
Plan—What to do about each problem listed in assessment: orders to write, things to check.
Note: Every time you have a new patient, you should think of a differential diagnosis and a plan of action to go about finding out what is wrong. Develop a rationale for your treatment plans by reviewing the literature. Don’t be afraid to give your opinion or to make mistakes. We are all here to learn and to work together to make patients get better.
Presentation of Patient Who Has Been Here a While
Present in SOAP format (if complicated pt, use systems approach)
Patient identification and problem list—one-sentence summary of pt, why he or she is here and problem list.
Subjective—Problems overnight, pt or parent concerns, subjective comments on nursing notes
Objective—Vitals—detail significant changes or fevers, otherwise “vitals normal.” Significant PE changes or features, tests or labs.
Assessment—problem list
Plan—by problem
Example Presentations
Patient Who Has Been Here a While-Identification
JR is a 14 yo boy with cystic fibrosis here for pulmonary exacerbation. He is on tobramycin and Timentin day #8 through an infusaport. Getting CPT q.i.d. He also has diabetes secondary to his CF. He is on b.i.d. insulin (give units and type).
| SOAP | SOAP Notes |
|---|---|
| S | He states today that he is feeling improved, his cough is much less productive and less frequent. |
| O | Vitals: normal |
General appearance: up in hallways, active, no resp distress |
|
Lung exam: scattered rhonchi throughout rales esp in R upper lung field posteriorly. |
|
Pulmonary function tests yesterday were much improved over admission. |
|
Sputum culture from admission grew pseudomonas sensitive to tobra and ticarcilli. |
|
CXR yeast showed improvement in the RUL infiltrate. |
|
| Blood sugars have ranged from 89-142. | |
| A | Pulm exacerbation of CF: doing well on current management |
Diabetes: good control on current insulin regimen |
|
| P | Will continue current antibiotics; check pulmonary function tests in 3 days. If continued improvement, consider discharge |
New Admission
KC is an 8 yo known asthmatic who was feeling well until two days prior to admission, when she developed cold symptoms with runny nose and sore throat. That evening she had difficulty sleeping due to cough and wheezing, but responded to using her albuterol inhaler every 4 hrs. The following day she developed increasing shortness of breath and wheezing and by evening needed to use her inhaler every 2 hrs. She slept restlessly and her mom noted much “pulling in of her chest” with breathing, and fast labored breathing even after using the inhaler. Her lips appeared bluish to her mom. She brought her to the emergency room. Mom denied any fevers. Cough seemed unproductive of sputum. No paroxysms of cough. No known exposure to pertussis. Several members of the family have had cold symptoms. Her asthma symptoms began at age 3. KC has been hospitalized one other time for asthma 2 yrs ago. She has never been intubated. She has been able to handle her exacerbations of asthma at home with use of albuterol inhaler intermittently. Her last exacerbation was 5 months ago. All exacerbations have been associated with viral illnesses. No known environmental/allergic triggers to asthma.
Immunization history
Allergies
Meds on admission: albuterol inhaler
Birth history
PMH: One hospitalization age 6 for asthma, hospitalized 2 days; no ICU admissions; multiple episodes otitis media, tube placement age 2 years
FH: Mother and sibs with asthma
PT Profile: Single mom, many family stressors; mom tends to minimize patient’s symptoms.
PE: On arrival in ER
RR 44, HR 120, BP 110/70, T 37.2 axillary, pulse ox 88% on room air. In general, she appeared tired, sitting up and leaning forward, bracing herself on her arms, moderate respiratory distress with nasal flaring, intercostal retractions, use of abdominal musculature and neck musculature with breathing. Color was pale with mild cyanosis of lips.
HEENT exam unremarkable
Lungs: marked decreased breath sounds throughout, few wheezes
CV: RRR, tachycardic, no murmur
Remainder of the exam was unremarkable; no clubbing of the nail beds
No labs were done on admission.
Course since admission: She was provided supplemental oxygen and pulse ox improved to 97% with 2 liters by nasal canula. She was given nebulized albuterol in the ER with improvement in air movement and an increase in wheezing, respirations more comfortable. An IV was started and she was given methylprednisolone loading dose and q 6 hrs.
PE now appears comfortable, mild intercostal retraction, no nasal flaring, lungs have coarse rhonchi, many wheezes throughout, good air movement to the bases.
Assessment: 8 yo girl with exacerbation of asthma, responding well to current treatment.
Plan: Wean oxygen to keep O2 sats >93%; change albuterol nebs to q 4 hrs scheduled and q 2 hrs. prn, change to oral prednisone to complete a 5-day burst; arrange for home nebulizer. Consider discharge to home when on room air, good control of wheezing on q 6 rd nebs and if tolerating oral prednisone. Will need education regarding new medications and asthma-prevention issues.