Pediatrics in the Inpatient Setting

Goals:
In summary, the goal of learning in the inpatient setting is to develop problem-solving skills and approach to patient care rather than to learning isolated facts about the limited number of illnesses which may be encountered. The student needs to learn about the differential diagnosis of the presenting complaint and the common, less severe presentation of the illness. You should remain open minded to other diagnoses and not focusing too early on what appears to be an obvious diagnosis. Use a patient-centered approach rather than an illness-centered approach to identify important psycho-social and practical needs of the patient, as well as learn about the details of medical management.

Expectations
1. Using the problem oriented medical record, students will perform a complete history, physical examination (including plotting growth parameters), assessment, and plan on no more than two new patients in a 24 hour period unless mutually agreed upon by the student and resident. The senior resident on the floor will be responsible for patient assignments, observing a representative sampling of a student's history and physicals, and discussing the students' assessment and plan. The student will be responsible for the follow up of the patient, accumulating lab data, recording progress notes and presenting the patient in a succinct manner (with notes, if necessary) on rounds. Students are discouraged from reading their notes on presentations. The ward medical attending and/or senior resident will sign off on all student's, progress notes, and orders in a timely fashion. Each H&Ps should be copied and given to the teaching attending for feedback.

2. You are expected to read a standard pediatric textbook and/or pertinent literature regarding each patient's problems) and to report to the ward team on how this information impacts on the patient's care. Failure of the student to do this on a consistent basis will be reflected in the final evaluation.

3. You may perform specific procedures which require patient/parent informed consent with resident supervision and consent of the attending physician. STUDENTS SHOUID NEVER PERFORM A PROCEDURE THAT THEY'VE NEVER DONE BEFORE OR THAT THEY FEEL UNCOMFORTABLE ABOUT.

4. You should be involved in all medical and paramedical activities regarding your patients including mobilization of ancillary services to facilitate an easier, more efficient hospitalization. Patient care activities take precedence over conferences (exceptions are to be discussed with the senior resident on service).

CONTENT TO BE MASTERED (See curriculum)

Medical Genetics and Congenital Malformations
Common Acute and Common Chronic Pediatric Illnesses
Therapeutics Fluid and Electrolytes Poisonings
Emergencies Child Abuse

MEDICAL RECORDS
A system of medical record-keeping, devised by Dr. Lawrence Weed, is an excellent method of teaching a logical approach to patient diagnosis and proper management. The essence of the system is that medical records should be directed toward unsolved problems, rather than toward specific diagnoses

A. INITIAL HISTORY AND PHYSICAL

The chief complaint, present illness, review of symptoms, past medical history and family history are recorded as always. However, the present illness is organized around specific problems (i.e., a paragraph dealing with the history of shortness of breath, a paragraph dealing with chest pain, etc.) rather than in a chronological order. The chief complaint should be in the patient's or parent's own words. Always list the informant and his/her reliability.

The second change involves replacement of a list of "impressions" or "differential diagnoses", which often prematurely assign diagnoses and often omit important problems, with a "problem list." The problem list should include both "active and inactive" problems, the latter being problems which are not now troublesome but could conceivably be a source of future difficulty
A problem maybe defined in any of three categories, depending on it's degree of a resolution. These are:
1. A symptom or physical finding, e.g., fever or hepatomegaly.
2. A pathophysiologic finding, e.g., congestive heart failure.
3. An abnormal laboratory finding, e.g., anemia, hematuria

An urinalysis, blood smear and tine tests are part of the initial physical examination and constitute base laboratory data.

If the etiology of any problem is known with a high degree of certainty, this may be stated (e.g., if congestive heart failure secondary to mitral insufficiency). If the etiology is not known, that should also be stated (e.g., anemia of undetermined etiology). Lists of different diagnoses should not appear in the problem list; however, tests are ordered on the basis of differential diagnostic possibilities.

B. IN1TIAL PLAN (1 - 2 hours after admission)
This should include a specific plan of each problem listed. Each plan should be arranged in the following manner on the yellow SOAP progress notes.

1. Diagnostic assessment and plan for the collection of further data related to the problem. It is here that differential diagnoses for unsolved problems may be listed. For example:
a Jaundice, undetermined etiology
1. hemolytic anemia
a hemoglobin and hematocrit
b. examination of RBC morphology
c. reticulocyte count
d. direct and indirect bilirubin

b. Serum hepatitis
1. SGOT
2. total bilirubin
3. alkaline phosphatase
4. Hepatitis B antigen
2. Plan for treatment with specific procedures or drugs.

3. Plans for education of the patient.

C. PROGRESS NOTES
Progress notes should pertain to a specific problem and should be written in the SOAP format or other organized way on yellow progress notes. It is obviously not necessary to list all problems in each progress note. All of them should be reviewed, however, at regular intervals.

D. FLOW SHFFTS (diabetes, epilepsy, hypertension or chronic disease)

A separate sheet listing data pertaining to a specific problem in temporal sequence is most useful. The most obvious application for this device is in situations where many parameters are changing rapidly and simultaneously (e.g., diabetic acidosis, gastrointestinal hemorrhage). Another application is the use of such sheets to summarize pertinent data on a specific problem which has accumulated over several years and which may be difficult to find in a mass of old records.

E. FINAL STEPS

1. Final progress notes & discharge instructions.
2. Face sheet - diagnosis, procedures, operations, complications, disposition, outcome and sign
3. Discharge summary - should include a statement of the status of each problem in the same form as outlined for progress notes.

ALWAYS SIGN AND DATE EACH PAGE. Have your charts read and co-signed as quickly as possible by the appropriate resident. A complete history and physical must be in the chart within 24 hours of admission

Site Info

Gen Med 1

Gen Med 2

Resp-Neuro

Holy Cross

Anne Arundel Medical Center