PEDIATRICS ROTATION

PEDIATRICS

ROTATION #3 - PEDIATRICS OUT PATIENT

Pediatric out patient was very fun. It was different in that you circulate throughout different areas to get a true experience of the different services offered for children’s health. Here are the places I got to go to.

1. Pediatric Emergency – MTA (Minor treatment area)

This was similar to emergency. As with all emergency rooms patients are triaged based on severity. As the name suggests MTA implies non life threatening concerns. I saw

Children with Fever – Usually means the child has a cold and the parents are concerned. First we rule out infections first such as ear, throat and urinary tract infections. Then we provide reassurance that there is no “bad” underlying cause. 

Rash – The story I came across the most was the patient had a fever then broke out into a rash. With children rashes are common in viral infections again reassurance is key.

Cough – This again goes with the rash and fever. Most children develop a post-viral cough which could persists for up to weeks after being sick.

Broken bones – I was told by one of the docs that it is common to see broken bones in children but the key is to make sure not to expose the child with too many x-rays. Here I saw fractures on fingers, radial and ulnar fractures as well as displacements.

Concussion

Herpes gingivostomatitis

Ear infection

Strep throat

2. Pediatric Physiotherapist (PT) and Occupational therapist (OT)

Was able to observe what PTs and OTs do with children with developmental delays

3. Pediatric Speech Language Therapist

Learned the approach of a speech language therapist for children. I also learned that parents are a big influence in inducing positive changes.

4. Fetal Alcohol Spectrum Disorder Clinic

I was able to observe how a child is screened for a possible fetal alcohol spectrum disorder

5. Shadowed a Pediatric Nurse Practitioner

Here I was able to do some well child/baby exams as well as see some concerns such as cough and fever.

ROTATION #4 - PEDIATRIC IN PATIENT

Felt like that cat in this rotation :P

This rotation is definitely the most different from the ones I had previously. In pediatric in patient you work with children who have been admitted to hospital. This is a typical day

  

7:00 am – Meeting with the team and sign over from overnight. You are assigned your patients that you are responsible for the day. This can be between 3 - 6 depending how many people you have on your team that day. 

7:30 ~ 9:00am – You pre round on your assigned patients. This includes asking the parents how their child did overnight, any concerns ie. If they are admitted for diarrhea ask if there were any episodes. If they are admitted due to asthma exacerbation ask if the patient required any puffers overnight. This also includes a focused physical exam. What is also important is determining urine output and ins/outs. This ensures the child is well hydrated.

To calculate urine output 

Urine output = Total urine volume (mL) / Time (hr) / Weight (kg)

Ex. A kid had a urine volume of 500mL in 8 hr and weighs 32kg

 Urine output would be 1.95 cc/hr/kg

For infants urine output should be >1cc/hr/kg for children >0.5cc/hr/kg. If less this is oliguria and may suggest dehydration or renal problems

9:00 -12:00 – Rounds

The team including yourself, other students the sr. resident and attending discusses and sees each patient on the service. For your patients you introduce them ie. 5 y/o F admitted for diarrhea. Then you talk through the problem list and the plan for each problem. You might also call other services for consults such as pediatric cardiology and pediatric gastroenterology

Afternoon - The afternoons can be very busy. You are responsible for calling the services that you’ve consulted for your patient and determining if they have seen them and what they recommend. This can mean going to their chart to see if the other services have written suggestions as well as checking if any results has come back from any tests that were sent. You are also responsible to write SOAP notes on each of your patients.

S = subjective – This is what the parents told you about how the night went or if the child said they felt pain or felt better.

O = objective – this includes vitals and lab results as well as what you found on your physical exam

A/P = assessment/ plan – This is where you write your problem list and your plan. Always include nutrition/hydration and discharge planning (Disposition) Example.

1.       Diarrhea – monitor, pending labs for GI, abdominal x-ray scheduled tomorrow

2.       N/H (nutrition/hydration) – standard pediatric diet, monitor ins/outs, daily weights

3.       Disposition – when diarrhea has resolved and cause has been determined.

 4:00 pm – sign over to the person on call.

ADMISSION NOTES

Another crucial thing that you learn is how to do a thorough admission note. This includes.

1. Date/Time

2. ID & Chief complaint

3. History of present illness

                - includes hydration status # diapers #stool, fluid intake

                - Emergency room – management

4. Past Medical History

                - including past hospitalizations

5. Birth History

6. Medications/Allergies

7. Immunization status

8. Development – milestones (Gross, fine motor and social, language)

9. Diet

10. Family Hx

11. Social Hx

12. Adolescent – HEADDSS (home, education, alcohol, drugs, diet, sex, suicide, depression)

13. Review of systems

14. Physical Exam

15. Labs & Imaging

16. Impression

17. Problem List/ Plan

This would take me 2.5 – 3 hours. Take time to read through the entire chart and understand what the issues are. The internet will be handy for this.

SUMMARY OF THE THINGS I DID/SAW

- How to present cases

- Admissions

- Fever in newborn – full septic workup in children from newborn to around 2 months

- Croup

- Bacterial tracheitis

- Pneumonia

- Asthma exacerbation

- Diarrhea

- Constipation – fecal impaction

- Failure to thrive

- Feeding intolerance

- ALTE – acute life threatening episodes – usually a parent saw their child go limp or saw perioral cyanosis but the episode resolves after the parent picks the child up

- Brain lesions

- Anorexia Nervosa

- Seizure

- Social issues – parenting/abuse

- Eczema

- Perinatal infections – TORCH (Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes infections)

- UTI

- Heart murmurs

This rotation for me was eye opening and overwhelming. Working on the wards you get to see the relationships of the different professions ie. Nurses, residents, students and different services. With pediatrics inpatient you need to spend time studying around your cases. The best way to think about it is to think of what would do if you were the sole care provider of the patients that were assigned to you. You should be spending time looking into their problems and developing a plan. That way during rounds you have a plan ready to present to your sr. resident and attending.

Overall I’ve learned a lot in the pediatric rotation as a whole. This was by far the toughest rotation yet. :S 

How I looked during and a few days after pediatrics inpatient :P