Month: October 2020

Hello!

I wanted to give you an inside look on my pediatrics rotation. I am actually really passionate about kids and they just light up my day. I have to say, I usually feel physically tired at the end of the day, but I don’t feel mentally or emotionally drained when I work with kids. It’s really hard to! They are always a joy to be around (for me anyways).

Pediatrics is another core rotation. This means that I will have another shelf or COMAT exam at the end of my rotation. Most students work with a pediatrician in clinic for their core rotation. That way, you get to see a lot of well child examinations and really get a good look at growth through the ages.

I actually had my core rotation with the pediatric hospitalist group! Thankfully, I got to do well child exams and examine newborns during my ob/gyn rotation in family medicine/ob. I also got to do circumcisions during that rotation as well. For this rotation, there was a much different feel as we were inpatient.

Much sicker children.

Much higher acuity.

Note taking is also very different from your typical outpatient notes. It is still a SOAP note (in theory anyways), but your most detailed note is the H&P when they first get admitted. More on that later.

Schedule/Daily Work Hours

This rotation was a little farther away from my last one, so I did have to get up earlier and drive farther. Not my favorite thing to do since I dislike mornings, but you do what you need to!

Around 7:15/7:20am: I get to the hospital and go up to my floor.

7:20-8am: I am reviewing notes on what happened last night and rounding on my patients. The floor can hold 19 rooms (2 kids per room), but they don’t typically like to double up in the rooms unless they have to. As a medical student, if I don’t have any patients that I’m following I MUST round on two of the patients on the floor. And I need to have seen my patients before huddle and before the provider comes to the floor. Some days I was able to push myself and see more than 2 patients.

8 am: Huddle. Huddle involves everyone in each child’s care to be present so everyone knows what is going on and what the plan is. On my floor, the nurses present their patients and any updates overnight to the physician. Pharmacy, social work, nutritionists, and child life (enrichment and counseling) are all present during this.

Depending on when Huddle ends we will start rounding.

8:20/9am -10:30/11am is rounding. This time is very very variable. And if we get a lot of admits in the morning or consults, rounding will be slid in-between. Generally we take this time to check in on each patient and update the parents on what we are going to do. Not all the patients on the floor belong under the hospitalist. Some patients are under trauma (burn and MVC patients), some are under Hem/Onc (cancer patients). Everyone else is under the hospitalist group. We may also have someone in the PICU (down a few floors from us) to see as well.

After rounding the physician usually works on any discharges that they have. I use this time to work on my notes or look up information on the diseases some of our patients have. Some days we have a lot of discharges, others we have maybe one.

After rounding to 3/4pm. This is where we take consults, the provider calls for other consults to help with patient care, and check up on labs/imaging or order anything new. Most of these patients have a lot going on, and usually take up more time than you would expect. Some days we have barely any consults, some days we have a lot.

When the provider or myself isn’t taking a consult, they usually take that time to teach! The busier the day = less teaching. And after each time I take a consult or round on a patient, I need to write a note.

For example, today we had a kid come as a step-down from the PICU to our unit. So I was sent to the PICU to examine the patient and get a history to get things started while the provider did something else. I was also sent down to the ER as the ER wanted us to admit a child. So I again started that history and physical for the physician. At the same time, we had two transfers come in as direct admits; I took one and my provider took the other. And finally we had another ER admit. While that was going on, my provider was also trying to get a specialty consult appointment set up so we could discharge a patient, and consult another child’s geneticist who was being admitted.

They usually send me home around 3pm, unless we were busy and I would stay a little later. The latest I have stayed is around 5 pm. The unit I’m on has a rule about students not really being there past 3 and not to work on weekends. After discussing my hybrid situation with my attending, most of them are okay with me coming in on weekends to spend some extra time learning.

Notes

So note taking is a bit different for inpatient. It is still a SOAP note, but depending on the type of note will depend on how much information you put in it.

H&P: This is the note you write when admitting someone. So if you get a consult to admit from the ED, see the kid after a transfer to the floor from another hospital, or see the kid from a direct admit from their pediatrician, you do this type of note.

It involves a full HPI, ROS (multiple systems), and PE (multiple systems). The more complete = the better. You need to verify PMHx, SHx, meds, allergies, Family Hx, all that jazz. Some physicians also want a good social history; which for kids involves who they live with, if they go to school/daycare, any pets, any activities they do. If they are still infants or young toddlers, you need a birth history from mom.

Assessment for the H&P isn’t always what you end up diagnosing them with. For a lot of kids that fall under “failure to thrive” I usually put poor weight gain. Because one person’s definition of FTT is different from another. And a lot of times physicians use FTT instead of poor weight gain. So my initial assessment/dx is a working dx or a symptom unless something specific was found on workup.

Plan is much more in-depth and usually involves going by system. So a plan for an admit may look like this:

• Resp: on RA, oxygen, albuterol q.2 hours, etc.
• CVS: Hemodynamically stable. Will monitor vitals q.8 hours.
• GI: (usually includes diet). PO diet as tolerated. Consult dietician and SLP for evaluation.
• Renal/Endo: I never put anything here unless its a specific case for it.
• ID: If we did a respiratory panel, stool panel, etc we would put findings here. This is also where we may put antibiotic plan here.
• Neuro: If there I something specific like EEG or MRI or near consult we put that here. Otherwise usually Tylenol/motrin for pain will be put here as well.
• Social: where we typically put that we’ve updated the parents on plan.

Any labs or imaging can be put under their associated section OR I usually pt it above with a statement to make it nice and neat. It just depends on how you do it.

Progress notes: So this is what you put on a patient that you’ve rounded on. Since insurance only covers one “bill” a day, only the day shift rounds on patients in the mornings. The night doctor doesn’t do any notes that would fall under progress. Some physicians like to add the day # at the top.

HPI for this is usually any updates since last written evaluation. So this can be that management was switched in the afternoon or evening, and how they did overnight. Did they spike a fever? Did they vomit? Diarrhea? How did they sleep? (very important in gauging kids). Did they eat? Can they tolerate PO? Were they playing yesterday? All of that is important.

ROS you don’t typically do for a progress note since the HPI is an update on how they are doing.

PE can be limited to a few systems. If it is a newborn/infant, you need to do a full exam every.single.time. Otherwise, I usually do constitutional, skin, eyes (if old enough), heart, lungs, belly, and neuro. You can add/subtract from there. Or you can do a full exam each time. It’s up to you.

A&P: similar set up as before. You either define/find a better diagnosis or continue to use the previous working diagnosis. Or maybe you use the working diagnosis and add on more based on findings and how the kid is doing. Plan is set up the same way. Any changes to treatment, any added medications, consults, labs/imaging need to be added. If you have an idea of what you are looking for before you discharge them, make sure that is noted in your plan. Otherwise the next attending on may not remember from sign-out what you’ve told them.

Discharge note: This is a brief HPI, PE, pertinent lab/imaging findings, and A&P. Plan should include follow up with their pediatrician and any other specialists, any follow up labs/tests you need them to get, and what symptoms they should look for that would prompt re-evaluation. Any medications you are discharging them with and how to use them along with any patient education needs to be in the plan and patient papers. Most of the subjective can be wrapped up nice and neat in a summarized “present” during their whole time there. Some providers like to have a full few paragraphs on the course of what happened while there. Others do less involved. PE should be pretty damn near normal or as normal as they can get for their condition before sending them home. Like, you shouldn’t be sending home a kid who is in respiratory distress and it shows that on your exam.

Cool things to see on the floor:

• Trauma (although I didn’t manage any of those and neither did the hospitalist).
• Burns (also trauma)
• hem/onc patients (we didn’t manage this, but interesting to look up and study)
• pyelonephritis
• asthma exacerbation
• bronchiolitis/croup/pneumonias. One pneumonia was chlamydia related!
• appendicitis
• LOTS of pyloric stenosis at this floor. Like holy crap.
• omphalitis and cellulitis
• scalded skin syndrome vs toxic shock syndrome vs weird allergic reaction
• osteomyelitis
• diarrheal diseases
• so much failure to thrive/poor weight gain. Some of them are due to dehydration, some due to poor feeding schedules/too much given by parents/not enough given/not feeding at night. Some are the kids had a virus and everything got out of whack. Some of them are actually from some pretty serious diseases.
• Febrile seizures was also pretty common to see.
• Hirshprung’s disease.
• rule out Kawasaki’s
• Seizures (several had associated genetic diseases)
• Duodenal hematoma (that was actually really interesting to look into management)
• BRUE
• Seizure management and workup
• Abuse cases 🙁
• Kids with genetic metabolic diseases and the fall out/recurrent issues that occur with those.

I most definitely spent time reading during clinic while my providers were doing phone calls or charting. That allowed me to cement a case with what I saw and with the information about it.

What are some major things I learned?

Well besides how inpatient medicine works and learning about kid diseases, I learned more about interacting with patients than I thought I would.

1. I need to know my cases well, because parents will still ask me questions. I need to do my best to answer with correct information; and if I don’t know, I need to be able to defer it for when my attending arrives.
2. Just because you are worried about a disease course for a specific disease/problem, doesn’t mean you need to tell the parents all of that. Lesson learned. That mom didn’t like me very much.
3. You need to do a full exam. Every. Single. Time. As a student, it is time for you to practice. Not good at listening to murmurs? Listen to all the hearts. Not good at finding pulses? Practice. Plus, since your differentials aren’t fantastic yet, it helps you possible catch something you weren’t sure could be helpful!
4. I have learned that even though you can complaint or discuss something in person, you cannot write certain things in your notes. Even if it is causing you issue with management of a patient. Word truthfully, but without accusing or painting a non-neutral picture in the chart.
5. I really really like kids. And I really really like babies. Which is NOT helping me push off having children.

Hope this was helpful, and good luck on peds!