DEPARTMENT OF PEDIATRICS
SOURCE BOOK 2005/2006
THIRD YEAR PEDIATRIC ROTATION
TABLE OF CONTENTS
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PEDIATRIC DEPARTMENT LIST......................................................................... |
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GOALS & OBJECTIVES . |
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DESCRIPTION OF 3RD YEAR CLERKSHIP.......................................................... |
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TOPICS YOULL WANT TO KNOW WELL........................................................... |
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PEDIATRIC HISTORY........................................................................................... |
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PHYSICAL EXAMINATION................................................................................... |
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COMMUNICATING WITH CHILDREN AND THEIR FAMILIES............................. |
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PEDIATRIC REFERENCES.................................................................................. |
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DEPARTMENT OF PEDIATRICS -
Holley Allen, MD Pediatric Endocrinology 794-4441
Samuel H. Borden, M.D. Director, Med/Ped Program 794-3998
Hilary J. Branch, M.D. Ambulatory Care 794-5523
Dennis Brenner, M.D. Pediatric Endocrinology 794-4441
James Burns, M.D. Chief, General Pediatrics 794-5083
Thomas J. Campfield, M.D. Newborn Medicine 794-5350
Francis J. Duda, M.D. Pediatric Pulmonology 794-4137
Christine Fabel, R.N., PNP Ambulatory Care 794-2515
Hussien M. Farrag, M.D. Newborn Medicine 794-5350
Donna J. Fisher, M.D. Pediatric Infectious Diseases 794-5379
Robert S. Gerstle, M.D. Ambulatory Care 794-5066
Herbert Gilmore, M.D. Pediatric Neurology 794-7331
Carolyn Goldstein, M.D. Ambulatory Care 794-5523
Deborah Hanks, R.N., PNP Ambulatory Care 794-2515
Anthony Jackson, M.D. Pediatric Neurology 794-7329
Alicia Johnston, M.D. Pediatric Infectious Disease 794-5843
Barbara A. Kelly, M.D. Newborn Medicine 794-5350
Nancy M. Kloczko, M.D. Ambulatory Care 794-5075
Laura P. Koenigs, M.D. Adolescent Medicine 794-8897
Gary Levine, M.D. Ambulatory Care 794-0555
Stephen A. Lieberman, M.D. Pediatric Critical Care 794-4137
Naomi London, M.D. Ambulatory Care 794-8897
McKiernan, Christine, M.D. Pediatric Critical Care 794-4137
Susan McQuiston, Ph.D. Child Psychology 794-7324
Kathleen M. Meyer, M.D. Newborn Medicine 794-5350
Nancy H. Miller, M.D. Adolescent Medicine 794-3988
John OReilly, M.D. Ambulatory Care 794-0555
Yvonne M. Paris, M.D. Pediatric Cardiology 794-4137
Annabelle Quizon, M.D. Pediatric Pulmonology 794-7040
Edward O. Reiter, M.D. Pediatric Endocrinology 794-5060
Mathew Richardson, M.D. Pediatric Hematrology/Oncology 794-5316
Gary F. Rockwell, M.D. Assoc. Director, Newborn Med. 794-5350
Beth Rosen, M.D. Pediatric Neurology 794-7342
Robert W. Rothstein, M.D. Newborn Medicine 794-5350
Sherrie Rouse, R.N., PNP Ambulatory Care 794-2515
Thomas W. Rowland, M.D. Pediatric Cardiology 794-4137
Matthew Sadof, M.D. Ambulatory Care 794-5523
Bhavesh L. Shah, M.D. Director, Newborn Medicine 794-5350
Jean L. Sheeley, M.D. Ambulatory Care 794-5523
Barbara W. Stechenberg,M.D. Pediatric Infectious Disease 794-5379
Philippa Sprinz, M.D. Pediatric Hematology/Oncology 794-5316
Cheryl Tierney, M.D. Ambulatory Care 794-5087
Chrystal Wittcopp, M.D. Pediatric Endocrinology 794-0555
Kathy Hall Education Coordinator 794-5084
Ann Marie Asselin Schedule Coordinator 794-8897
TUFTS UNIVERSITY SCHOOL OF MEDICINE
PEDIATRIC CLERKSHIP
Goals & Objectives
Objectives By the end of the rotations, students will be able to:
GOAL I Communications
·
Written
Identify
the chief complaint; organize the HPI with chronologic development; document
the ROS, PMH, FH, SH; document immunization status; generate problem list;
write a differential diagnosis and management plan.
·
Oral
Present
a directed history and physical in an organized manner.
·
Patient
Demonstrate
the ability to use age-appropriate vocabulary in communicating with patients in
both the inpatient and outpatient setting.
Frame different types of questions in an appropriate manner. Learn to identify and address psychosocial
issues.
·
Parents
Demonstrate
the ability to communicate with parents around the diagnosis, treatment and
plan for their child. Demonstrate
interviewing skills around taking history from a second party (parent). Learn to identify and address psychosocial
issues.
GOAL II Communications
·
Demonstrate
awareness of normal vital sign values for age.
Assess normal growth and development.
·
Refine
exam skills: examination of tympanic
membranes; recognition of strabismus; palpation of nodes; distinguish between
inspiratory and expiratory obstruction; auscultate murmurs and palpate femoral
pulses; palpation of liver and spleen; assessment for rebound tenderness;
perform rectal exam; to be able to examine hips in a newborn; recognize
arthritis and abnormal gait; recognize jaundice, petechiae, urticaria,
vesicles, morbilliform rashes.
GOAL III Communications
·
Infectious
disease: Students will demonstrate familiarity with
the presentation and management of otitis media, tonsillitis, pneumonia,
sinusitis, cellulitis, sexually transmitted diseases, pelvic inflammatory
disease, sepsis, meningitis, periorbital cellulitis, urinary tract infection,
pyelonephritis.
·
Nephrology:
Students will demonstrate familiarity with principals of oral and
intravenous rehydration, and calculation of maintenance fluids and
electrolytes.
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Pulmonology/allergy:
Students will understand the diagnosis and management of cystic fibrosis
and asthma.
·
Hematology/Oncology:
Students will demonstrate familiarity with the clinical presentation and
management of anemias, lead poisoning, bleeding diathesis, childhood leukemia
and lymphoma.
·
Gastroenterology:
Students will recognize and understand the treatment of jaundice. Students will demonstrate familiarity with
the etiologies and management of infectious diarrhea; management of encopresis/constipation.
·
Neurology:
Students will recognize and understand the treatment of febrile and
afebrile seizures. Students will
demonstrate a diagnostic work-up for headache and treatment of migraine and
evaluation of head trauma.
·
Endocrinology: Students will recognize the understand the
management of D.K.A., hypothyroidism, hyperthyroidism, congenital adrenal
hyperplasia, and growth hormone deficiency.
·
Cardiology:
Students will recognize and understand the management of cyanotic
newborn. Students will differentiate
pathologic murmur from physiologic murmur.
Students will recognize and understand the management of common
pediatric arrhythmias (eg. SVT, V tach).
·
Dermatology:
Students will demonstrate the ability to diagnose and understand the
management of viral exanthemas, eczema, diaper dermatitis, and acne vulgaris.
Goal IV Health Promotion and Disease
Prevention
·
Students
will identify appropriate schedule of immunizations.
·
Students
will understand the current recommendations for infant, toddler, and child
nutrition.
BAYSTATE PEDIATRICS
Baystate Medical Center is both the primary care hospital for greater Springfield and the tertiary care hospital for Western Massachusetts. The inpatient pediatric service has 56 beds (including a 6 bed PICU) while the Newborn ICU has 57 beds. The ambulatory service sees 30,000 scheduled patients annually (ER visits not included) and provides newborn care for many of the 6,000 babies delivered each year at Baystate. Our teaching staff includes 30 full-time members, three pediatric surgeons, and over 70 pediatric practitioners. Needless to say, the house staff plays a major role in teaching. We have 21 pediatric residents and 10 medicine-pediatric residents on the service at any one time.
GOALS OF THE CLERKSHIP
Our general goal is to provide you with a broad exposure to pediatrics. We absolutely do not expect to turn you into a pediatrician in six weeks, We expect you will (a) acquire a pediatric knowledge base, (b) become comfortable taking a history and performing a physical for each pediatric age group, and (c) be able to recognize a seriously sick child. You should also be able to distinguish normal from abnormal development. We hope you will have fun, too.
CLERKSHIP STRUCTURE
The Pediatric Clerkship includes a three week ambulatory rotation and a three week inpatient rotation. The inpatient rotation is based in the Centennial Building (North Campus) while ambulatory clinics (general) meet in the High Street Health Center (140 High Street) or at 3300 Main Street (near North campus) (subspecialty). While on the ambulatory half of the rotation, some daily cross-town commuting is inevitable. The drive takes about ten minutes.
INPATIENT
During the inpatient experience, you will be assigned to one of four teams. Generally your team will include a supervisory resident, an intern and yourself. One of your responsibilities will be to complete a significant number of admission evaluations, one (or more) each day you have an opportunity to admit. Sometimes you and your resident will evaluate a new patient together. Usually you will take the initial history in this situation. At other times you may interview a patient on your own. After you obtain the history and physical, you will have a chance to independently derive a problem list. You should be able to discuss your assessments with the team and then help to develop a plan for diagnosis and treatment.
Your write-ups will become part of the permanent record. Organize your formulation in a problem-oriented fashion. Be sure to include thorough assessments and plans for each active problem. Assessments for major problems should incorporate complete differentials.
You will also be a participant in ongoing care. In general you will follow two or more patients at a time. You will be responsible for performing a daily exam and assessment on each of your patients. Make sure you have thought through your daily plan for each patient before the start of rounds. Daily progress notes will be written in accordance with the original problem list (and must be countersigned). You are encouraged to write orders and carry out procedures but all orders must be countersigned immediately and all procedures must be supervised by a house officer or attending. You should be aware of all diagnostic evaluations and treatment regimens prescribed for your patients.
The inpatient schedule is found on one of your handouts. Time not utilized by conferences and rounds or patient care activities can be utilized for independent learning.
You will take night call while on the inpatient service. Your call nights will correspond to your team's. This means every fourth night, including weekends. You are expected to carry out an admission workup while on call. Having completed this responsibility, you are considered "off duty" at 22:00. You can certainly stay later (to follow-up an interesting patient, for example), but that is up to you.
The routine changes somewhat on the "post-call" day. Your team's house staff (who have probably worked all night) will go home after attending rounds. For the remainder of that day you will be supervised by the house staff on the "long-call" team. You will still follow your teams' patients and attend regular conferences.
TIP
Any effort to search out and share information on patients will be greatly appreciated by the members of your team. Try to review a new topic each day and present a 5 minute "bullet" on rounds.
AMBULATORY
Your schedule for the three weeks on ambulatory consists of (a) one week in the newborn nursery from 8:30 to 12:00 with afternoon clinic from 1:00 to 4:00 at the High Street Health Center and (b) two weeks of general and subspecialty pediatric patient visits at the High Street Health Center, 3300 Main Street, and at Holyoke Pediatrics. On Tuesdays Pediatric Grand Rounds is held from 8:00-9:00 (except one Tuesday a month when it is from 8:00-10:00). Note that Tuesday morning nursery rounds will begin at 8:00 AM. You are expected to attend the 7:45 AM Core Lecture Series all mornings except Tuesdays.
At most Wesson Memorial clinics, you will see patients alone. Physician and nurse practitioner preceptors are always available for consultation. No diagnostic or therapeutic interventions should be made, and no patient is allowed to leave the clinic without a preceptor having reviewed and supervised the care you have provided. Similarly, if you are having difficulty with a patient or parent, for whatever reason, or feel uncomfortable with a clinical situation, ask your attending or nurse practitioner supervisor for assistance.
Dr. Carolyn Goldstein oversees your ambulatory pediatric experience. She can help you with questions on the schedule, feedback, or just about anything else relevant to outpatient pediatrics. She is a valuable resource person so please take advantage of her insights and advice.
OTHER CLINICAL EXPERIENCES
Students have requested a Newborn ICU experience. We require you spend one evening with the on-call NICU team (until 10-11 PM). This is a chance to attend high risk deliveries, see newly admitted infants with a variety of problems and join the team for work rounds. This works out best during your week in the Newborn Nursery.
PROFESSIONAL BEHAVIOR
Professional behavior is required at all times on the rotation, but especially in patient care settings. Dress should always be appropriate. White coats are not required but you must wear an easily readable name tag.
Patients should not be discussed in public areas. It is too easy to breech confidentiality, a basic right of every patient. When speaking to patients and families, try to avoid jargon. Keep explanations simple. If you don't have an answer, don't be afraid to say so. You can either find out the answer and get back to the family, or you can let your resident or attending respond.
Treat your patients and families respectfully.
CONFERENCES
While on both ambulatory and inpatient, you will attend the following conferences, all held at the North Campus:
Grand Rounds is held Tuesdays at 8:00 (except the 2nd Tuesday when it is from 8:00-10:00AM) in Chestnut Room 1A & B (Chestnut Bldg.). Guest lecturers, as well as Baystate faculty, discuss topical pediatric problems. These meetings are well attended by the entire pediatric community.
While on the Inpatient Ward you will also meet with the Pediatric Chief Resident twice a week to go over physical exam skills.
The Core Lecture Series designed solely for students, meets approximately four times a week at 7:45-8:30 AM usually in the Porter Conference Room (5A) (Springfield Unit). Applicable references taken from "Nelson Essentials of Pediatrics," should be read before each lecture. We assume you will acquire a comprehensive understanding of all the material presented.
Other equally important conferences which meet less frequently include Ethics Conference, Newborn Medicine Conference, and the Pediatric Case Conferences. These will be discussed in more detail at your orientation.
READING
The primary textbook utilized for this course is Nelson Essentials of Pediatrics, 3rd edition, edited by Behrman and Kliegman and published by Saunders. It is well organized, well referenced, concise and quite readable. See the reference list on Page 29 for additional texts.
Another valuable reference you should review is "A Guide to Physical Examination" by Barbara Bates. Please read the very informative chapter on the physical exam of infants and children by Robert A. Hoekelman. (chapter 17, pages 447-512).
Hopefully your readings will not be restricted to the core topics. Patient interactions should stimulate reading on a broad range of topics. Essentials of Pediatrics is well suited to a review of diverse pediatric topics since its length allows for a nearly complete reading over 6 weeks. If more in-depth information is required on a particular topic, check the reference list at the end of each chapter in Essentials. These reference lists usually cite relevant pages in Nelson Textbook of Pediatrics. Other valuable reference texts are Pediatrics by Rudolph and Hoffman and Principles and Practice of Pediatrics by Oski.
While on the subject of references, I should mention that the resources of the Baystate Medical Library will be available to you during your stay. This facility, located on the North Campus in the Chestnut Building, has many texts and all the major pediatric journals. It also has the OVID CD-ROM system for medical literature searches. If you are not familiar with the system, the library staff can help you get started. In addition, there are pediatric cases on computer disks on reserve in the library for med students only that should be taken advantage of. One is called MEDCAPS with cases on diskettes and a newer Interactive Pediatric Cases is set up from a CD-ROM. The Department of Pediatrics also maintains small libraries on the ward and in the clinic.
You will be given a list of pertinent Internet web sites for both Pediatrics and General Medicine. You may use Netscape in the library for free and are welcome to explore its uses in Pediatrics.
FACULTY PRECEPTOR
During your stay at Baystate, you will be assigned a faculty preceptor. You will meet with your preceptor on a weekly basis while on inpatient. At a minimum, you will (a) present and discuss patients you have evaluated and (b) review your write-ups. Xerox copies of write-ups should be handed in to your preceptor on a weekly basis, as they are completed. Other potential activities include case discussions, consideration of ethical questions or career guidance. The faculty preceptor should also play some role in providing feedback to the student.
The preceptor will expect to hear from you by your first week on inpatient. It is your responsibility to contact the preceptor and arrange the first meeting. Because you will get very busy, very quickly, it's best to do this early.
EVALUATION
Your performance on the rotation will be assessed by the faculty and house staff. A composite evaluation will include input from (a) the residents on your inpatient team, (b) the ambulatory faculty, (c) your ward attending, (d) preceptor, and (e) other teaching faculty. The composite evaluation and grade should be submitted to the medical school within 6 weeks of completion of your clerkship. In addition to this formal feedback, you should receive ongoing feedback from your supervisors throughout the rotation. This information is very important to your education so if it is not forthcoming, please don't hesitate to ask for feedback.
In addition to the Pediatric Board exam given the final Friday of the rotation at Tufts, you will also take a written clinical test. This is an essay test using cases covering general peds concepts. The clinical test is usually given the last Wednesday of the rotation and is worth 25% of your final grade.
You will also have a chance to evaluate us in the last week of the rotation. We try to update and improve the learning experience each year and your input is critical in the continuation of this process. Your time spent completing this survey is greatly appreciated.
COMMUNICATION
Despite our best efforts to keep the clerkship running smoothly, problems will arise. If you have questions or concerns at any time, please call either Dr. John OReilly, Clerkship Director, (ext. or beeper 44877) or Kathy Hall, Clerkship Coordinator (ext. 45084). We can only help if we know about problems.
SCHEDULE CHANGES
Occasionally students will have last minute requests for schedule changes. This is sometimes a problem, particularly on ambulatory where patients have been scheduled to see you long before your arrival at Baystate. If a situation arises that necessitates some schedule change, please let Kathy Hall (ext. 5084) know as early as possible.
CAREER ADVICE
If you think you might be interested in pediatrics as a career choice, please let us know about that too. Dr. Paris would be happy to discuss career options with you as would Dr. Reiter, Chairman, Department of Pediatrics and Dr. Barbara Stechenberg, Program Director.
TOPICS YOU'LL WANT TO KNOW WELL:
1. Normal development and major milestones
("walk at one, talk at two") Do a DENVER developmental screening exam on EVERY patient that comes in and you'll get a much better feeling for age-appropriate skills.
2. Infant Nutrition
Know approximate required cals/kg/day for the different ages (like to see newborn >120, 100 at 1 yr., etc.) Know your basic calorie content of infant formulas (normally 20 cals/oz (30 cc/oz)) and differences in protein (milk vs. soy vs. elemental amino acids). Get a good history for how much, how often and calculate it out. Have a sense of current recommendations for introduction of solids/fortified cereals at 4 months (depletion of iron stores at that time) etc.
3. Dehydration--vomiting & diarrhea
Be able to get a history including how much, how often, possible exposures. Know possible etiologies (infectious vs. mechanical (pyloric stenosis)), and basics of treatment/fluid replacement.
4. Failure to Thrive
Definition; etiologies (organic versus inorganic); symmetric vs. asymmetric (head, wt. ht, all decreased vs. head nl, wt |), general w/u (feed and observe, r/o malabsorption, occult disease, i.e., metabolic, infectious (HIV), check chromosomes).
5. Sepsis
What organisms are common at what ages, what is appropriate w/u at each age.
6. Neonatal hyperbilirubinemia
Etiologies (indirect vs. direct, physiologic/breast milk vs. pathologic), time of peak, (3-4 days of age in formula fed, up to 10 days with breast fed infant); those
increased risk (premature, bruised, septic, maternal meds, blood group incompatibility); w/u (type and coombs, CBC, reticulocyte count); treatment with phototherapy (exchange transfusion).
7. Respiratory Distress
A. Lower airway - etiologies (RSV bronchiolitis, bacterial vs. viral pneumonia, CHF, etc.).
B. Upper airway - etiologies (foreign body, croup, epiglottitis, retropharyngeal abscess), classic radiological findings (thumb print, staple sign).
8. Neonatal Apnea
Definition (>15-20 sec.) h/o color change, ? assoc. bradycardia (<200 bpm); is it related to SIDS? Risks (preemie, sib., ? position), W/U (r/o sepsis, seizure, CHD, IVH, GER, home monitoring.
9. Cerebral Palsy
Catch-all term for central motor dysfunction (Does NOT imply mental retardation), UNKNOWN etiology (probably prenatal, not a labor and delivery problem), diagnosed by motor delay, often subtle before 1st year of life, spastic and non-spastic types, treated with early and aggressive rehabilitation (PT, OT, Speech therapy).
10. Cystic Fibrosis
Presentation in infancy (meconium ileus)/ childhood (recurrent pulm. infections, loose greasy stools), pathophysiology (abnormal Na-Cl channels), diagnosis (sweat test), clinical course (pulmonary infections, sinusitis, pancreatic insufficiency, +/- diabetes).
11. Seizures
Febrile, prevalence, prognosis, treatment; defn. of tonic-clonic vs. absence, generalized vs. partial, meds for each.
12. Child Abuse
Story inconsistent with findings; Physical exam (check for sexual abuse, retinal hemorrhages), W/U = skeletal survey, head CT, ophtho. exam. Mandated report, to Department of Social Services.
13. Congenital Heart Disease
Know Tetralogy of Fallot, patent ductus arteriosus, Ventricular septal defect (most common cause of murmur), coarct of the aorta, and then there's every other imaginable anatomy (transposition of the great vessels, hypoplastic left heart, tricuspid or pulmonary atresia), Marfan's.
14. Trisomy 21
Clinical findings (facial features, simian crease, usually developmentally delayed, hearing loss), associated abnormalities (endocardial cushion defects, thyroid dysfunction, cervical spine instability, high incidence of leukemia, cataracts, seizures).
15. GER
Prevalence (i.e., all infants), sequelae (esophagitis, FTT, aspiration/bronchospasm), w/u (pH probe), treatment (thicken feeds, head of bed up, medications).
16. Other G.I. Disorders
Abd. pain, diff. dx according to age--intussusception ("currant jelly stool"), Appendicitis (periumbilical then RLQ, fever, leukocytosis, sterile pyuria), Meckel's, Hirschsprung's, Inflammatory bowel disease (Crohn's, poor growth secondary to disease as well as to steroid treatment).
17. Anemia
Polycythemic at birth, "physiologic nadir" at 2-3 months, nutritional deficiencies (outpt. w/u).
18. Sickle Cell Disease
Clinical manifestations, painful crises, (tx with narcotics and hydration), aplastic crisis (assoc. with parvo virus), sequestration crisis, asplenia at age 5, susceptibility to encapsulated organisms (streptococci)).
19. Pediatric Oncology
Hematologic cancers: Leukemia (most common = ALL, >70%
curable), Lymphoma (adolescents). Solid
Tumors: Brain tumors (usually infratentorial
vs. adults which are supratentorial), know symptoms of increased intracranial
pressure, (AM headache, wakes child up from sleep, vomiting, abnormal gait,
loss of milestones), Neuroblastoma
(commonly regress spontaneously unrecognized, present with abdominal mass in
under 4 yr. old, usually metastasized), Wilm's tumor from embryonic
kidney. (Also presents with abdominal
mass). Bone tumors (osteosarcoma,
20. Childhood HIV
Incidence of perinatal transmission (approx. 30%), probably at birth vs. transplacental infection; tests (Mom's antibody until age 15 mo., possible viral culture), clinical manifestations (adenopathy, FTT, HSM, Thrush, recurrent bacterial infections, PCP, LIP).
21. Endocrine Disorders
Diabetes (presentation of new onset, polyuria, polydipsia, wt. loss), pathophysiology (antibodies to islet cells), course (insulin dependence but possible "honeymoon" period), DKA.
PEDIATRIC HISTORY
The properly-obtained history of a sick child serves as more than an essential information-gathering and diagnostic tool. It provides a unique opportunity to evaluate the child in his/her family and social setting and the family attitudes towards disease and hospitalization. During the interview the physician builds an effective relationship of trust with the child and his parents by expression of concern, warmth, confidence, and interest in the child and family, as well as in the illness itself. The quality of this relationship directly affects the accuracy of the history as well as cooperation with subsequent therapy or recommendations.
In general, it is best for the interviewer to allow the parents (or child, depending on age) to take the lead in telling their story of the child's illness and then recapitulate at the ending with specific questions. Occasionally an excessively verbose historian will require "steering" by the physician, but frequent interruptions to ask questions, despite possible savings of time, destroy historical continuity and inhibit a useful parent- physician relationship. Likewise, it is best to avoid hasty scribbling as the history is told. Jotting down pertinent times and places during the conversation and writing the entire history afterwards allows a more comfortable and complete interview.
The following outline is suggested as a guide for obtaining a thorough and diagnostically useful pediatric history:
1. Informant:
Short comment suggesting the reliability of the history and the accuracy of the observations by the historian.
2. Chief Complaint:
Give the main reason(s) for the child's visit to the hospital. Often the informant's own words are appropriate; usually a single symptom and its duration is all that is needed.
3. History of Present Illness:
"The patient is a 3 y.o. white male admitted for evaluation and treatment of respiratory distress. This is his first hospital admission, and he was in good health until ____ days prior to admission when he developed [signs & symptoms]." This is followed by a chronological description of the illness.
in the case of a young child, or a
child with a presenting problem which may be related to a problem during
pregnancy or delivery, the second sentence should read: "The patient is the product of a [list
specific complication] complicated/uncomplicated pregnancy, born by [mode of
delivery] at [gestational
age in weeks] to a Gravida ____ Para ___ woman with [list non-pregnancy related
problems]. The neonatal history is
significant for [pertinent positives and negatives (sepsis, jaundice, heart
murmurs, etc.)]. Then continue with
chronological history. Be sure to
describe the complaint in detail. The
pneumonic COLDERR may help you characterize the problem:
C haracter
O onset
L ocation
D uration
E xacerbating factors
R elieving factors
R adiation
4. PAST HISTORY
A. Prenatal:
Health of mother during pregnancy, exposure to rubella, viral infections, drugs, x-rays, weight gain, maternal smoking, alcohol consumption, maternal age, parity, Rh compatibility.
B. Birth:
Duration of pregnancy, birth weight, easy or difficult labor, forceps or C- section delivery, anesthesia, onset of respirations, cry? Resuscitation necessary?
C. Neonatal:
Cyanosis, jaundice, convulsions? Required oxygen or incubator? Breathing problems? How long in the hospital?
D. Feedings:
In infants, note if breast or bottle fed, record type of formula, amount taken per day. Feeding difficulties. Vitamin supplements. Note when and what solid foods introduced. In older child record present diet.
E. Development:
Birth weight, weight at 6 months, 1 year, etc., if known. Any sudden gain or loss in weight. First tooth. Is the child's general growth similar to sibs? Using the Denver Developmental Scale (include milestone from each category: social, language, fine motor, gross motor), record age of major milestone attainment: smiles, laughs, crawls, walks alone, first words, first sentences. School grades, comparison with sibs.
F. Behavior:
Is he a happy child? Difficult child? Does he get along well with other children? Reactions to new situations, strangers, school? Excessive demands for attention. Temper tantrums. Problems with bowel or bladder training. Other habits such as thumb-sucking, nail biting,, masturbation, medications.
G. Past medical history:
Susceptibility to infection. Past illness, surgery, hospitalizations. Immunizations, allergies, accidents, injuries, medications.
5. FAMILY HISTORY:
Draw a family tree and record ages and health of members. Special attention to mental retardation, early deaths, miscarriages, childhood illness, convulsions, allergies, congenital malformations, skin lesions, diabetes, growth failure, thyroid disease. Other medical problems of adulthood (myocardial infarction, hypertension, malignancy, etc.) may or may not be relevant in each case, so use your judgment whether or not to ascertain these details (certainly these illnesses are always important in the outpatient area).
6. SOCIAL HISTORY:
Frequently emotional difficulties detected through clues in the social history may assume a major role in the child's present illness as well as interfere with his well-being in general. Avoid cursory questions (i.e. "are there any problems at home?"). Nonsensitive inquiries can create a falsely positive picture of child-family relationship and result in children at risk for behavioral difficulties being missed. The following is an example of a model social history.
"Now let me ask you a few questions about your family ..."
A. Where are you living now? How long have you lived there? (Who else lives at home? Who sleeps where?).
The child of a family that moves frequently may suffer feelings of insecurity with change in school and friends. Battering of children also is known to occur more often in these families.
B. Are you married? What is your relationship with the patient's father? Did you plan to have a child at this time? (How long were you married when you had this child?).
Overprotection is frequent when the mother marries late in life, when there is a period of difficulty conceiving a child, when there have been several previous miscarriages, or when a last child in a large family is born after a long interval. Rejection is more often seen young parents, when marriage was precipitated by premarital pregnancy, or when the child's birth was an economic burden. Does anyone in the family work outside of the home?
C. How old is the patient's father? Education level? Does he get much time to spend with the child? What role does he play in disciplining the child? What kind of person is he (i.e. perfectionist, demanding, easy going?). Wide differences between ages of the patients and difference in religion or in educational background may lead to interparental strife. Education level and occupation of the parents gives a general clue to the child's intellectual capacities. Parental demands placed upon the child and reaction to his misbehavior are frequently at the core of psychogenic illness in children.
D. How old is the patient's mother? Does she work outside of the home? Unemployed? Does she use a baby-sitter? Does this child get on her nerves? Mother's age, health, education level and role in discipline? What kind of person is she?
E. Parent's upbringing: "What was your childhood like?"
F. What problems do you have with marital or financial difficulties? Is there any chronic illness in the family (especially alcoholism)? (Do either parents have a number of psychosomatic complaints?).
G. What is the child like? How do you describe him (outgoing, introvert, courageous, cautious, hyperactive, slow, etc.)?
H. Does the child go to day care or a baby-sitter? What grade is the child in? How does he do at school? What are the parent's response to success or failure? Extracurricular activities?
I. Does he play with older or younger children? Is he a leader or follower? What is his aptitude at sports? Does he read? Watch TV? What books or programs?
J. For adolescents, remember the pneumonic HEADSS:
H ome environment
E ducation/employment
A ctivities outside school
D rugs
S exuality
S uicidal ideation
when discussing sexuality try to be gender neutral (i.e., Have you had a romantic/sexual relationship," instead of "do you have a boy/girl friend?").
7. REVIEW OF SYSTEMS:
This should supplement the present illness. Information recorded there need not be repeated (merely state "see HPI").
Skin: rashes, eczema, hives, jaundice, birthmarks, bruising, pruritus, dry skin, excessive sweating
Head: injuries
Eyes: eyes crossed, squinting, redness, discharge, past visual exams.
Nose: nose bleeds, draining, snoring, mouth breather
Mouth & sore throat or tongue, tongue protrusion, dental problems, tooth Throat: development
Lungs: difficulty breathing, cough, hemoptysis, wheezing, hoarseness, chest pain.
Heart: murmur, shortness of breath, cyanosis, recurrent respiratory infections, chest pain, palpitations.
GI: anorexia, nausea, vomiting, dyspepsia, diarrhea, constipation, abdominal pain, color of stools.
GU: bedwetting, dysuria, urine color, frequency, flank pain, character of urinary stream, vaginal discharge, menstruation.
Extremities: weakness, deformity, joint pain or swelling
Neurological: headaches, dizziness, incoordination, convulsions, staring spells
PHYSICAL EXAMINATION
While the physical examination of older children differs little from that of the adult, the evaluation of infants and small children often requires a good deal of versatility and adaptability. In this age group careful observation becomes of particular importance, and a short initial period of play or conversation with the anxious child gives valuable information regarding neurological, cardiac, pulmonary, emotional, and nutritional status and pays dividends in helping establish rapport with the small patient.
In general, it is best to begin with the least threatening portions of the physical examination (such as evaluation of extremities, chest, and abdomen) and leave ear, throat and rectal exams until last. Allow the child to sit, lie in mother's arms, or assume any position where he/she is secure rather than insisting upon a supine position on the examining table.
Thoroughness is essential. Remember to observe, auscultate, percuss, and palpate areas examined. The child must be completely undressed, but usually not all at once. Respect the child's modesty.
The physical examination record should begin with the following
information:
Height ______________ Percentile for age _____________
Weight ______________ Percentile for age _____________
Head circumference (infants) ________ Percentile ________
Temp ______ Pulse _________ Resp ______ BP _____
General Appearance:
Include a statement of the child's general development and nutrition, unusual positions assumed, mental status, activity, comfort level, degree and acuteness of illness, and any evidence of distress.
Skin:
color, cyanosis, jaundice, eruptions, turgor.
Lymph Nodes:
location, size, tenderness
Head:
Shape, symmetry, sutures, bone defects, size and tension of fontanels (posterior usually closed by 2 months; anterior usually closed by 12 to 18 months, occasionally as early as 9 months), hair and scalp.
Eyes:
Vision: Test grossly, visual fields, test in all children old enough to cooperate, strabismus (position of light reflex in both eyes), cover test. Nystagmus; conjunctivae, sclerae; cornea (haziness, opacities); pupils (size and shape, reaction to light); iris, lens; funduscopic examination.
Ears:
Hearing, external ear (deformity or unusual shape, pain with movement of ear), canal wall, drum, mastoid.
Nose:
Deformities, condition of airway, color and state of mucosa and turbinates, discharge (amount and character), sinus tenderness or swelling. (At birth, maxillary antrum and the anterior and posterior ethmoid cells and sphenoid sinus are present. However, the latter does not assume clinical significance until approximately the fifth year of age. At two to four years of age, pneumatization of the frontal sinus occurs, but it is rarely a site of infection until after the 6th to 10th year).
Mouth and Throat:
Teeth - number and condition, gums buccal mucosa, tongue, palate, tonsils, posterior pharynx, voice hoarseness), cry and stridor.
Eruption of Teeth
6 months 2 (lower central incisors)
1 year 6 - 8 (incisors)
18 months 12 - 16 teeth
2 1/2 years 20 teeth
Neck:
Rigidity, swelling, lymph nodes, salivary glands thyroid, position of trachea.
Chest:
General shape. Any deformities (In infancy the chest is almost round. As the child grows older, the chest normally expands in the transverse diameter).
Lungs:
Percussion; breath sounds (usually bronchovesicular in children), rales, bronchi, friction rub, inspiratory or expiratory wheezes.
Heart and Cardiovascular System:
Inspection - cyanosis, edema, clubbing of fingers, respiratory distress. Palpation: location of apex beat (apex beat is normally felt in 4th interspace just to left of the midclavicular line in child under age 7 years. After this, it is felt in 5th intercostal space in the midclavicular line). Thrills.
Heart:
Auscultation; heart rhythm, quality of heart sounds, splitting of second heart sound. Murmurs - location, intensity, quality, duration, transmission. Radial and femoral pulses.
Abdomen:
Shape (distended, flat) tenderness, rigidity, palpable organs or masses, hernia, visible peristalsis, ascites, bowel sounds.
Back:
Spinal shape (posture-lordosis, kyphosis, scoliosis), masses, tenderness, limitation of motion.
Genitalia:
In male, record descent of testes, presence of hydrocele, state of foreskin, adequacy of urethral meatal orifice, malformations as hypospadius. In female, note abnormalities as fused labia minora or imperforate hymen, urethral or vaginal inflammation or discharge, pubic and axillary hair. A vaginal examination is not routinely done.
Anus:
Patency, fissures, fistulae, hemorrhoids, state of sphincter. Rectal examination whenever child has an abdominal problem.
Extremities:
asymmetry, anomalies, unusual length, pain and tenderness, temperature, swelling, deformities. Joints, (heat, tenderness, swelling, effusion, redness, and limitation or pain in motion). In infants always test for dysplasia/dislocation of hips.
Neurology:
There are three forms of Neurologic examination in children which are largely age-related but may overlap in any particular child.
In addition to evaluating neurologic integrity, the examination of the newborn is designed to yield information regarding gestational age. This is based on a particular set of responses of the neonate, usually those of tone and primitive reflexes, that normally mature during pregnancy (see Dubowitz LMS: Clinical assessment of gestational age in the newborn infant, J Ped 77:1, 1970).
The neurologic evaluation during infancy and early childhood provides information regarding the progress of psychomotor development and includes certain "soft" tests which may reflect subtle abnormalities in neurological function.
The Denver Development Screening Test is an example of such an evaluation. While complete psychological testing is not warranted on all children in this age group, selective items should be tested not only to grossly assure developmental normality but also to provide the examiner an opportunity to observe the expected behavior of children in different age groups.
The traditional evaluation of mental status; motor, sensory and cerebellar function; cranial nerves; and reflexes is pertinent to all age groups.
Labs: There are no routine labs.
Other tests: x-rays, CT scans
SUMMARY
Summarize pertinent findings from history and physical. "This is a 3 yo white male with a 3 day history of progressive difficulty breathing, who presented with a fever of 103, diffuse wheezing, left lower lung field egophony, and moderate hypoxemia. He also has a history of poor weight gain, chronic diarrhea, and is less than the fifth percentile for weight."
Don't say - "This is a 3-year-old with pneumonia & probably previously undiagnosed cystic fibrosis."
ASSESSMENTS
Identify the patient's problems, then provide an assessment for each one that is active. For simple straight forward minor problems, the assessment may be one or two sentences. For more involved major problems, you will have to generate a differential diagnosis. Refer to pediatric textbooks (i.e., Nelson, Rudolph, Oski) for help with this task.
PLANS
Describe your plan for evaluating, treating and following up each problem (not your resident's plan), and how the evaluation will rule in or out elements of your differential diagnosis. List the problems in order of seriousness, Example:
1. Respiratory distress -
- Evaluation - CXR to r/o pneumonia, ABG to access severity
- Treatment - supplemental O2 to keep SaO2 >90%
- antibiotics, bronchodilators
- Follow-up - daily exam, daily peak flows
BAYSTATE MEDICAL CENTER
DEPARTMENT OF PEDIATRIC SERVICES - CHILD LIFE PROGRAM
GUIDELINES TO WORKING WITH HOSPITALIZED CHILDREN
1. Always INTRODUCE YOURSELF and explain who you are. A child meets many different people during his hospitalization. Be as friendly and natural as possible.
2. Try to speak DIRECTLY to the child. KEEPING YOURSELF AT HIS HEIGHT whenever possible. Always speak in a quiet pleasant tone of voice.
3. BE HONEST. ALWAYS TELL A CHILD THE TRUTH. Certain procedures are painful and you will lose the child's trust if you say it will not hurt and it does. Try to focus on something pleasant for the child when the procedure is completed.
4. WHEN A CHILD CRIES, DO NOT command him or her to stop. Crying is sometimes the only way a child copes or expresses his feelings. Instead, encourage him to stop by saying, "I could understand you better if you stop crying," and then take the time to listen.
5. IF A CHILD WANTS TO GO HOME, reassure him or her that "No one is allowed to live in the hospital," and that they will be going home (if this is true) when they are all better.
6. CHILDREN NEED STRUCTURE. Limits are set at home and at school. To help normalize the environment and show them we care, we set limits and discipline the children in our care. Please respect the limits we set and the structured day of the children by VISITING, CUDDLING, AND HOLDING THE CHILDREN ONLY WHEN IT IS APPROPRIATE.
7. NEVER MAKE ANY PROMISES to a child unless they are true or you intend to carry them out.
8. LET A CHILD MAKE CHOICES whenever possible. Give praise often and use it as encouragement.
9. NEVER DISCUSS A CHILD OR HIS/HER CONDITION when other patients or visitors can hear you.
10. NEVER DIRECT NEGATIVE CRITICISM AT THE CHILD; direct the comment toward the negative behavior. It is important that the child understands that you still like him/her but that you do not approve of his/her behavior.
11. NEVER GIVE A CHILD A CHOICE WHEN A REAL OPTION DOES NOT EXIST.
12. AVOID COMPETITION OR COMPARISONS between patients; someone's feelings are bound to get hurt.
BAYSTATE MEDICAL CENTER
DEPARTMENT OF PEDIATRIC SERVICES
PARENTS OF HOSPITALIZED CHILDREN
*The parent's level of anxiety is easily
communicated to
their child.
Therefore, helping parents will in turn
help the child.
1. Parents need to know that their child is receiving competent physical care.
- Make sure the child is clean, comfortable and gently care for so that the
parents can trust the care to others.
2. Parents need to feel important to their child and capable as parents.
- Greet parents often. Ask how they are doing as well as how their child
is doing.
- Ask parents about any special preferences that their child might have,
i.e., toys, games, stories, songs.
3. Parents need a chance to discuss their feelings about their child's hospitalization.
- Avoid making judgmental statements, praise or criticism.
- Avoid offering advice or pat answers. Through talking, people will often work
through their problems on their own.
- Show acceptance and interest by looking directly at the parent and showing a
willingness to listen.
4. Parents may need to learn more about being honest with their children.
- Be a model by being honest with the child and the parents.
taken from: Smitherman, CH: "Parents of Hospitalized Children
Have Needs, Too." American Journal of Nursing,
August, 1979.
ASSOCIATION FOR THE CARE OF CHILDREN'S HEALTH
CHILD LIFE RESEARCH PROJECT
RECOMMENDED VOCABULARY FOR MEDICAL EXPERIENCES
SUGGESTED VOCABULARY VOCABULARY TO AVOID OR EXPLAIN
Object Words
Needle Shot (Use only if child uses term first
indicating he/she understands and
relates to this medically.)
Injection
Poke
Stick (may confuse child)
_____________________________________________________________________
Rubber band (for tourniquet) Tourniquet (may use for older children)
_____________________________________________________________________
Special bed on wheels Stretcher ("stretch her" - can be confusing)
Guerney
_____________________________________________________________________
"Special Kind of sleep" Put to sleep" (confused with putting a pet
to sleep)
"Help you go to sleep" Anesthesia
_____________________________________________________________________
Small opening "Cut open"
Incision
"Make a hole" (too explicit; may leave child
feeling incomplete)
_____________________________________________________________________
Into the vein (I.V.) I.V. (not like ivy)
Intravenous (for older children)
_____________________________________________________________________
Medicine to help the doctor see Dye
Picture/big camera (for X-ray) X-ray (unless it's obvious child already
understands this term)
"The camera will move but won't CT Scan & other scans (only if explained
touch you." to child)
"Pictures of inside of you." M.R.I.
____________________________________________________________________
Caps - fits together Electrodes/EEG leads (too technical)
____________________________________________________________________
Intensive Care Unit (explain) I.C.U. ("I see you")
"A place you'll have your own
special nurse"
"A place where you'll get extra
special care"
____________________________________________________________________
Nothing to eat N.P.O. (too technical)
"Your stomach needs to be empty"
____________________________________________________________________
Bed O.R. table
____________________________________________________________________
Poop/pooh (or child's familiar Stool collection (confusion term - do you
term) sit on it? chair?)
____________________________________________________________________
Pee (or child's familiar term Urine specimen
____________________________________________________________________
Feeling Words
"It doesn't hurt" (ok to use when Hurt (Only if child uses this first, otherwise
you are certain it wont and may be setting up expectation that
child can only relate to that may become self-fulfilling.)
form of concrete reassurance.)
Ouch/"ouie"sore/ache Irritate
Pinch/Sting
Warm/cool feeling Burn (too threatening)
Cold
Squeeze
Tight hug (for blood pressure)
Fits snugly
_____________________________________________________________________
Odd/differential taste/smell Funny smell (may be confused with comical)
Unusual Bad tasting
Yucky (only after the fact)
_____________________________________________________________________
"Has this been harder than Bad (try to use softer language)
you expected?"
_____________________________________________________________________
"You may feel it in your throat" Scratchy (may set up negative expectation
due to connection with past
experiences with scratches)
Tickle
_____________________________________________________________________
Sticky (for electrodes)
_____________________________________________________________________
Full feeling
_____________________________________________________________________
LANGUAGE SPECIFIC FOR I.V.'S AND O.R.
Medicine in the bag;
- "You need different medicines to help you get better. Some is in the bag and some is added with the needle into the tube. You don't feel the needle."
- "It's a different way of getting medicine."
- "It's the quickest way to make you better."
_____________________________________________________________________
PRIOR TO SURGERY
- "Dry mouth"
- "You may have a dry throat when you wake up."
- "Your throat may be a little sore when you wake up."
- "This is where you say 'See you later' to you parents" (when parents can't stay with children until induction.)
_____________________________________________________________________
POST-OP SUGGESTIONS
- "Your stomach has been asleep and resting. It needs time to wake up. As your stomach wakes up you will slowly be able to drink and then eat food again."
PEDIATRIC REFERENCES
Basic texts:
Nelson Textbook of Pediatrics (15th edition)**
Behrman, R.E. and Vaughn, V.C.
W. B. Saunders Company, 1996.
Pediatrics (20th edition)**
Rudolph, A. and Hoffman, J. I.
Appleton and Lange, 1996.
Principles and Practice of Pediatrics
Oski, F.A.
J.B. Lippincott Company, 1990.
Pediatric Physical Exam:
A Guide to Physical Examination and History Taking (6th edition)
Bates, B.
J. B. Lippincott Company, 1995.
(See chapter 19 by Hoekelman)
Atlas of Pediatric Physical Diagnosis (2nd edition)**
ed. Basil Zitelli and Holly Davis
Mosby, 1992.
Pediatric Clinical Skills (2nd edition)
Richard Goldbloom
Churchill Livingstone, 1997.
Ambulatory Pediatrics:
Ambulatory Pediatric Care (2nd edition)**
Dershewitz, R.A.
J.B. Lippincott Co., 1993.
Primary Pediatric Care (2nd edition)**
Hoekelman, R.A. et.al. Mosby, 1992.
** indicates text found in Main Library