Schedule and Expectations for Medical Students on the Pediatric Ward
0700-0830 Prerounds:
On arrival to ward (0700), print out patient list on the computer and look at the board to see if there is a patient to pick up. The senior resident may have you pick up zero, one or two new patients. Once you have your list of patients to see, check in with the intern and start prerounding on these patients:
- Go to the Epic Chart and look at all orders and progress/consult notes written within the last 24 hours.
- Check in with the patient's nurse between 0700 to 0730 to see if there were any problems or changes with the child overnight. After 0730, the RN taking care of the patient during the night will have left so it is important to do this before he/she leaves.
- Look at all vitals and I’s and O’s. Note total number and timing of respiratory treatments in last 24 hours, if applicable.
- Examine the patient with the intern and gather information about how the child did during the night from either the patient or parents. It is helpful to try and coordinate your exam with the intern’s to minimize the number of exams each patient receives in the morning.
- Look at the Electronic Medication Administration Record (EMAR) in Epic to understand all medications given in last 24 hours, including prns.
- Look up all labs and any reports of radiological studies for your patient.
- Look at all films yourself to get practice and learn from them. Ask a resident or attending to help you.
0830-0900 AM Report: M,T, W, F in 11th floor conference room (Grand Rounds in 11th floor auditorium Thursdays 0800-0900.)
Rounds: 0930 Hood & Coast Teams:
Hood and Coast rounds usually are at the bedside of each patient for the patients on the general pediatric services. Rounds for the subspecialty patients vary. Ask your senior resident about rounds for any subspecialty patients you are following.
Presenting your patients during rounds: Because of time constraints, we all strive for concise and effective communication during rounds. This is especially important when presenting at the bedside in front of patients and family members. Your job is to present each patient in an organized fashion, focusing on their problem list, expanding on abnormalities yet avoiding tangents. This takes practice. The purpose of rounds is to assess the issues and plan the best treatment course for each patient. You should discuss the patient presentation and problem list with your intern and/or senior resident prior to bedside rounds. You should offer an assessment of what the diagnosis is (giving a differential diagnosis if it is unclear) and a plan by problems or systems. One caveat to presenting at the bedside: If cancer, Ebola virus or Mad Cow Disease aren't at the top of your differential diagnosis, it’s OK to leave it off the problem list. Every patient should also have a disposition plan. Please see the presentation guidelines at the end of this handbook.
1100-1145: After rounds, discharge patients, call consultants, write orders, do admissions with interns and resident. Update patient list on computer. Depending on the day, there may be a short didactic or bedside teaching session with the senior resident or attending in the morning after rounds or afternoon.
1145: Get lunch
1200-1300: MS3 Core Lectures (or Resident Noon Conference if no Core Lectures scheduled)
1300-1700: Admissions, complete work, go to procedures with your patients.
1700: Update intern and senior resident about your patients and update the patient list on the computer if needed.
1730: Go home if you are not on-call
Weekends:
If you are not on-call or post-call, you are not working. If you are on-call, arrive at 0700 and locate the list of patients to pre-round on, usually hanging in the workrooms on the xray view box. The post-call and on-call residents and students see and write notes for all the kids on both the Hood and Coast services. Resident check-out rounds start at 0900 and are in 9301 which is the conference room off the main DCH hallway in between 9N and 9S. The purpose of check-out rounds is to communicate to the on-call team as concisely as possible pertinent information about all the kids on both teams. Ideally, after rounds, the post-call people put their finished notes in the charts, tie up loose ends and go home. If there are discharges that morning, all the computercharting and prescriptions should be filled out ahead of time allowing the on-call team to admit new patients and get other work done. When you are on-call on a weekend day, you will be doing work (discharges, orders, admits) for patients on both teams.
Call:
You will be on-call every 5th night and the clerkship director determines the schedule before the rotation begins. You may wear scrubs when on-call (the scrub machine is in the back hallway of the 8th floor.) A call team consists of one senior resident, one intern and one student. Most of the time, you will admit patients who will be on your ward team. However, this is not a hard and fast rule, especially when one team is getting several admits and the other team isn’t. Remember, you can learn something from every patient so it is universally frowned upon to say that because you’ve already admitted three patients with bronchiolitis during your rotation you do not need to be involved with another one. It is not advisable to hibernate in the call room since you will learn the most from being with the on-call team, helping with cross-cover issues and being present.
For all patients you are actively involved with admitting, you should write a history and physical and put it in the chart after a resident or intern co-signs it. Your write-up should include an assessment with differential diagnosis and a plan by systems. There is no need to rush. Take your time to write a clear, organized, concise and thoughtful note. You may use abbreviations rather than full sentences. You are the historian – take your reader from the start of when the illness/condition occurred, up to the point at which you are seeing the patient in the hospital room. Included in your HPI should be a summary of any visits to a patient’s PCP or ED (including the day of admit) and reason for admission. Often this requires going through old chart notes or papers that come with the patient from the referring facility. Your admit note should reflect critical thinking. Print your note and give it to the attending and/or senior resident for feedback and critique.
Post-Call Afternoons:
During the clerkship, there may be a few afternoons with scheduled student lectures. If you are post-call, you are expected to stay for these teaching conferences but may leave once the conferences are done. If there are no scheduled conferences the afternoon you are post-call, you may leave after the MS3 Core Lecture.
Learning:
You are here to learn as much pediatrics as you can during your five weeks. Take charge of that concept. Ask residents to “teach on the fly.” Teach each other. Keep lists of learning issues. Create differentials at morning report and for each patient you admit. Do CLIPP cases early since they are a great way to learn.
Oral Presentation Guidelines for Medical Students
Three types of presentations:
- New/Full admits (<5 minutes)
- PICU transfers (<5 minutes)
- Daily/Interim presentation (<3 minutes)
New/Full Presentation - <5 minutes
Chief Complaint: one-line statement in the patient’s (or parent’s) own words
History of Present Illness:
Identify patient age, sex, and if applicable any chronic disease/conditions already diagnosed that are important for listener to know with respect to present illness. If there is no previous medical history, can state “previously healthy.”
· “3 yr old male with h/o asthma who presents with 1 d h/o SOB and wheezing” leads your reader to a different conclusion than
· “3 yr old male with h/o asthma who presents with 1 d h/o vomiting and diarrhea.” In this scenario, the asthma is irrelevant and should simply be included in the PMH section. You, as the historian, know whether the chronic diseases/conditions are important to your presentation since you have heard the entire history, done the physical exam, and reviewed any previous labs/studies prior to writing your note.
Duration of symptoms and qualifiers:
- “3 d h/o NBNB vomiting initially 1-2 x per day, increasing to q feed today and 2 d h/o watery diarrhea q 3-4 hours”
- “Pain” should have qualifiers: quality, quantity, location, alleviating/aggravating factors, timing, setting, and associated symptoms.
Any medications that were tried in the home and what effect they had.
The chronology of visits to PCP or ED and reason for admission and summarize the diagnosis given and any medications/labs/studies done for the patient while at these visits, up until the time at which they are sitting in front of you in the hospital room.
Example of an HPI:
“1 yr old male previously healthy with 2 d h/o NBNB vomiting q 2-3 hrs and 1 d h/o watery diarrhea q 15 minutes, decreased activity and only 1 wet diaper in last 24 hrs. Initially taking sips of PO apple juice and pedialyte, now refusing all PO. Whole family sick with V/D x 2 days. ROS negative for fever, rash, RN, cough or abd pain. Patient taken to PCP (Dr. Smith) yesterday, given phenergan PR and tolerated PO w/o emesis and sent home. To OHSU ED tonight with lethargy, continuing V/D and refusal to take PO. In ED, given 20 ml/kg NS bolus x 2, lytes significant for CO2 of 15, CBC and UA unremarkable, rota pend, admitted to DCH ward for rehydration and presumed viral gastroenteritis.”
ROS: Be sure to include pertinent positives and negatives. If applicable, you can state “ROS negative except as described in HPI.”
Past Medical History (conditions should be in chronological order):
Birth History if patient is young, or if relevant to HPI.
Any chronic diseases, when diagnosed, ongoing treatments for these, names of specialists following patient.
List number and reasons for acute clinic/ED visits over recent past.
Past Surgical History
Name of PCP/Clinic
Immunization Status
Developmental History
Diet
Medications: Include names, dosages, timing
Allergies: Include drug name and what reaction occurred.
Social History: Include who lives in the home, what city they live in, daycare exposure, what grade the child is in if school-age, tobacco exposure (ask, “does anybody smoke?” rather than “does anybody smoke in the home?” since most parents think that if they smoke outside, their child isn’t getting exposed to smoke), pets, recent travel, social stressors.
Family History: Start by asking if there are any children in the family with diseases or conditions they see a doctor for regularly. Ask about childhood deaths in the family. Less important here is Grandmother’s heart disease and Grandfather’s diabetes, unless of course they developed these conditions when they were children.
Physical Exam:
Vital signs: Temp, HR, RR, BP, O2 sat. Weight, Height, OFC (if <2 yr) and %
General, HEENT, Neck, CV, Resp, Abd, GU, Ext, Neuro, Skin
Labs/Studies: List any labs/studies done prior to admission, even if result is pending (and where they were done.)
Assessment: One line summary statement of HPI, PE, labs and most likely diagnosis.
- “3 mon old male with tachypnea, poor feeding, murmur and cardiomegaly on CXR, most likely congenital heart disease.”
If diagnosis is in question, list differential diagnosis in order of most likely to least likely. The assessment allows you to demonstrate your ability to think critically about your patients.
Plan: By problems (pneumonia, pyelonephritis, dehydration) or systems, for example:
FEN/GI (fluids, electrolytes, nutrition, gastrointestinal)
Pulmonary
Cardiovascular
Infectious Disease
Neuro
Heme
Renal
Disposition
Your plan should address abnormalities in PE, labs and studies, and should be based on your assessment above. Every patient should also have a disposition plan, which simply means what needs to happen in order to discharge the patient. As many people have specific expectations, ask your senior resident if your plan should be by problems or systems.
New Patient Admitted Overnight or After Rounds the Previous Day (<5 minutes)
This presentation is exactly like the new/full admit presentation above, except that after labs and studies you incorporate overnight events and any new developments (including changes in PE) since admit before going on to your assessment and plan. You do not need to state two assessments and plans. Most patients will be admitted in the afternoon or evening prior to your presentation in rounds. The idea is to capture how the patient appeared on admit, and then state any changes on your second exam and assessment the morning of your presentation.
New Patients from PICU (a.k.a. PICU Transfers) (<5 minutes)
This presentation can be initially confusing, especially if the patient has had a prolonged PICU course with multiple medical issues. Your job as the historian, is to review the initial History and Physical in the chart, as well as the PICU transfer note (unless the patient has stayed 24-48 hours in the PICU, in which case you can review the daily progress notes.) The key to this presentation is brevity. In essence, PICU transfer presentations should be thought of as an expanded daily presentation such that the subjective information is a summary of the PICU course. You can do this by systems if the patient is complicated with multiple systems involved, or simply state a few summary sentences about how and when the patient initially presented, why the patient was transferred to the PICU, and the PICU course. Then, progress to your objective data for the last 24 hours and proceed with a daily presentation format.
Daily/Interim Presentation (<3 minutes)
Use this format for patients admitted >24 hours ago. Brevity is important. You may omit the portions of subjective and objective data that do not directly relate to patient’s reason for admission or working diagnosis.
Identification: One line statement of name, age, working diagnosis and date of admit.
Subjective:
Yesterday: “Had ____ study or lab which showed _____ result”
Overnight: “Did well” or “Had difficulty due to _______”
Objective:
PE – Vitals (24 hr range and trend of T, HR, RR, BP, O2 sat)
I/O’s with UOP calculated as ml/kg/hour
PE pertinent positives and negatives.
Labs – can state which lab obtained and any abnormal values. State which labs are still pending. It is also helpful to report trends (e.g., “the hct today is 24, improved from yesterday when it was 22”)
Studies – radiological studies, echocardiograms, EEG, etc.
Medications – list names of medications (and dosages/timing if applicable e.g., albuterol MDI q 4 hr, last given at 0800)
Assessment: One line summary of name, age, working diagnosis, and response to treatment(s). If diagnosis is still in question, continue to state your differential from most to least likely. The assessment allows you to demonstrate your ability to think critically about your patients.
Plan: By problems or systems. Should address abnormalities in PE, labs and studies and should be based on your assessment above. Every patient should have a disposition plan.
General
Early in the rotation, practice giving your presentations to fellow students, interns, and the senior resident. This will help your confidence as well as improve your ability to communicate effectively during rounds and on the wards. Later on in the rotation, after gaining experience, you may not need full presentation practice. Please speak up if you feel you need more formal presentation practice, or have any questions about the presentation expectations in this handbook.
