Paediatric Clerkship Manual 2013/2014 Updated: August 2013
Transcription
Paediatric Clerkship Manual 2013/2014 Updated: August 2013
Paediatric Clerkship Manual 2013/2014 Updated: August 2013 Welcome to Paediatrics! This manual describes the structure and expectations of the Paediatric block in your clerkship. It includes a detailed list of objectives, and information about the examination and assessment process. This manual also includes information that we hope will make it easier for you to adjust to yet another clinical experience – lists of phone numbers, names of faculty and housestaff, dictating instructions, and recommended textbooks and websites. Please refer to your Clinical Clerkship Handbook for details about general clerkship requirements such as attendance, call, holidays, appropriate dress and conduct, orders, and procedures. The faculty and housestaff in London and in our regional sites of Chatham, Sarnia, Stratford, Owen Sound and St. Thomas are excited about helping you to have a challenging, stimulating and worthwhile experience. We, along with the Undergraduate Education Coordinator, Suzanne Belanger, are available to you at all times. We are committed to providing you with an outstanding educational experience. Please contact us with any questions, concerns, or suggestions for improvements. We welcome your feedback. Enjoy your rotation! Joanne Grimmer, MD, FRCPC Director, Paediatric Clerkship Associate Professor, Department of Paediatrics University of Western Ontario Eva Welisch, MD, FRCPC Deputy Director, Paediatric Clerkship Assistant Professor, Department of Paediatrics University of Western Ontario Table of Contents ORGANIZATION OF THE PAEDIATRIC CLERKSHIP 1 OBJECTIVES 2 CLINICAL TEACHING UNIT (CTU – RED & BLUE TEAMS) 8 CTU - Discharge Summary Dictation Template 11 EMERGENCY 13 Family Centred Care in the Emergency Department 13 Child Life Program 14 Tips for the Paediatric ER 14 RURAL REGIONAL PAEDIATRICS 16 Chatham 16 St. Thomas 16 Sarnia 17 Stratford 17 TEACHING SESSIONS 19 Paediatric Clerkship Peer Presentations 19 Attendance 19 RECOMMENDED RESOURCES 20 ASSESSMENT 20 Clinical Assessments & Assessment Forms 21 Peer Review 21 Mid-Rotation Assessment 21 Rotation Feedback Session & Exit Interviews 21 Final Summative Assessment 22 Criteria for Successful Rotation Completion 22 EXAMINATION 23 Oral Examination Questions 24 DEPARTMENT OF PAEDIATRICS FACULTY 26 PAEDIATRIC HOUSE STAFF 28 DICTAPHONE DICTATION SYSTEM – LONDON HOSPITALS CITY‐WIDE 29 SCOPE OF ACTIVITIES FOR SENIOR MEDICAL STUDENTS AT LHSC 30 Organization of the Paediatric Clerkship The clerkship in Paediatrics is 6 weeks in length. There are usually 14-17 clerks on Paediatrics in London per each block, with 4-6 clerks placed in Windsor each block. Under the Southwestern Ontario Medical Education Network (SWOMEN) some clerks will spend some or all of their Paediatric Clerkship at one of our five rural regional sites (Chatham, Sarnia, Stratford, St. Thomas and Owen Sound). In these communities, you will be exposed to all aspects of paediatrics including the care of neonates and inpatients, and emergency, ambulatory, and consultative practice. The clerkship at Children’s Hospital consists of three components: Clinical Teaching Unit (CTU) Emergency Selective 2 weeks 2 weeks 2 weeks OR: Rural Regional Paediatrics Selective 4 weeks 2 weeks London Contacts: Ms. Suzanne Belanger Education Program Coordinator Office: B1-431 Phone: 519-685-8500 x. 52328 Fax: 519-685-8156 Email: [email protected] Dr. Joanne Grimmer Paediatric Clerkship Director Phone: 519-685-8500 x. 58379 Fax: 519-685-8156 Email: [email protected] Dr. Eva Welisch Paediatric Clerkship Deputy Director Phone: 519-685-8500 x. 58010 Fax: 519-685-8156 Email: [email protected] Rural Regional Contacts: Ms. Linda Wright Windsor Campus Phone: 519 254 5577 x. 56424 Fax: 519 985 2613 Email: [email protected] or [email protected] Ms. Mary Peterson SWOMEN Rural Regional Phone: 519-661-2111 x. 86225 Fax: 519-661-4043 Email: [email protected] 1 Objectives The student is able to: 1. Demonstrate proficiency in acquiring a complete and accurate paediatric history with consideration of the child’s age, development, and the family’s cultural, socioeconomic and educational background. 2. Describe differences between the medical management of paediatric patients versus adult patients. 3. Recognize an acutely ill child and describe an initial management plan. 4. Demonstrate an approach to the following core clinical paediatric presentations (see below – chart 1). 5. Demonstrate physical examination skills that reflect consideration of the clinical presentation as well as the comfort, age, development and cultural context of the infant, child, or adolescent. 6. Demonstrate competence with the listed paediatric physical examination skills in addition to general physical examination skills (see below – chart 2). Demonstrate an approach to the following core clinical paediatric presentations including: differential diagnosis initial diagnostic investigations management plan Listed beside each core clinical paediatric presentation are key topics/conditions. The key conditions are neither a differential diagnosis nor a scheme (approach to the clinical presentation). The highlighted conditions are those that may be unique to paediatrics, that are essential, or that are common. The key conditions are those conditions that must be known in detail. Please use Nelson Essentials of Pediatrics (recommended textbook) as a guide to the depth of knowledge expected. SGY1 = small group year 1 SGY2 = small group year 2 Core Clinical Presentation Abdominal Pain Key Conditions Additional Guidance • • • • • • • • Appendicitis Intussception Constipation Recurrent abdominal pain of childhood Inflammatory bowel disease Infection (gastroenteritis and UTI) Henoch Scholein Purpura (HSP) • • Describe the clinical features of recurrent abdominal pain that suggest a pathologic medical condition (SGY2) List the major medical disorders that present with chronic or recurrent abdominal pain in childhood (SGY2) Describe the effect of IBD or other chronic disease on normal development in school age, adolescent and young adult patients (SGY2) 2 Altered Level of Consciousness • • • • • • Seizure Poisoning / intoxication Head injury / concussion Meningoencephalitis Hypoglycemia Metabolic disease (knowledge of specific diseases is not expected) • • • • • • Bruising and Bleeding • • • Dehydration • • • • Developmental & Behavioral Problems • • • • • • Idiopathic thrombocytopenic purpura (ITP) HSP Hemophilia / von Willebrand disease Meningococcemia Mild / moderate / severe dehydration Hypo / hypernatremia Diabetic Ketoacidosis • • • • Autism / Pervasive developmental delay Attention deficit hyperactivity disorder Isolated and global developmental delay Down Syndrome Fetal alcohol syndrome Temper tantrums • • • • • • • Diarrhea Edema • • • • • • • • • • Gastroenteritis Celiac disease Hemolytic uremic syndrome Inflammatory bowel disease Cow’s milk protein intolerance Toddler’s diarrhea Cystic fibrosis Nephrotic syndrome and proteinuria Nephritic syndrome and hematuria Acute kidney injury • • • • • Distinguish based on clinical presentation common toxidromes and their emergency antidotes Describe the pathophysiology of concussion and the protocol for return to sport Name and classify the most common CNS pathogens based on organism type and area of brain commonly affected Describe the difference in CSF findings in various CNS infections List preventive strategies, complications and long term prognosis for childhood meningitis (SGY2) Describe the different clinical presentations of inborn errors of metabolism Describe the clinical signs of dehydration Describe the principles of rehydration Explain the effect of hyperglycemia on fluid, electrolyte and acid-base status Describe the management of diabetic ketoacidosis Describe the concept of developmental surveillance Define the 5 developmental domains used in describing childhood development List major age-related developmental milestones through age 6 Describe typical patterns of social-emotional development Recognize major deviations from the normal range of development and behavior For a child with disruptive behavior, outline the prognosis for the following diagnoses: normal temper tantrums, ADHD and autism (SGY2) Outline a management plan for a preschooler with hyperactive, inattentive, impulsive and distractible behavior (SGY2) Identify infectious and non-infectious causes of diarrhea and describe the pathophysiology of these conditions Distinguish between transient, benign, and pathologic proteinuria Distinguish between pre-renal, renal and postrenal failure Describe non-renal causes of edema Describe initial fluid management in acute kidney injury and list the indications for dialysis 3 Fever Growth Problems • • • • • • • • • • • Meningitis Occult bacteremia / Sepsis (< 1 mon., 1-3 mon and > 3 mon.) Kawasaki disease Urinary tract infection Failure to thrive Hypothyroidism Precocious and delayed puberty Short stature Obesity Anorexia Turner’s syndrome • Describe the approach to the evaluation of fever without a focus • Describe the normal pattern of growth velocity in infants, children and adolescents Describe the typical and atypical timing and progression of sexual maturation Differentiate abnormal growth from normal growth variants (SGY2) Demonstrate correct plotting of growth parameters and calculation of body mass index Calculate target heights (predicted adult height) based on parental height (SGY2) Discuss the clinical signs of normal puberty and their usual progression (SGY2) List clinical features which would suggest growth hormone deficiency, syndromic or a genetic disorder in a child with short stature (SGY2) Describe the sequence of investigations for children with short stature (SGY2) Describe the history and physical exam findings in a patient with increased intracranial pressure Discuss the initial medical management of increased ICP Define the different types of child maltreatment (physical abuse, sexual abuse, neglect and emotional abuse) List the risk factors for child maltreatment Recognize normal and abnormal patterns of injury in children Describe characteristics of limb pain which would suggest child abuse (SGY2) Develop a systematic method to approaching acute limb pain (SGY2) List at least 4 important factors for the diagnosis of acute limb pain (SGY2) • • • • • • • Headache Inadequately explained injury (child abuse) • • • Migraine Brain tumor Increased ICP • • • • • • Physical abuse Abusive head trauma Sexual abuse Neglect Emotional abuse • • • • • Limp / Extremity pain Lymphadenopathy Murmur and/or cyanosis • • • • • • • • • • • • • • • • • • • • • Osteomyelitis Septic arthritis Juvenile idiopathic arthritis Rheumatic fever Transient synovitis Developmental dysplasia of the hip Legg Calve Perthes disease Slipped capital femoral epiphysis Growing pains Osgood Schlater disease Reactive / benign Cervical adenitis Malignancy (leukemia / lymphoma) Mononucleosis Innocent murmurs (Stills and venous hum) VSD Coarctation of the aorta ASD Tetralogy of Fallot Transposition of the great arteries PDA • • • Describe how to clinically differentiate normal from pathological lymph nodes in children (SGY1) • Classify congenital heart defects according to pathophysiology Describe the structural and dynamic changes that occur following birth in the cardiovascular system, including closure of the ductus arteriosus (SGY1) Compare the etiology of cardiac arrest in children vs. adults (SGY2) Describe an approach to resuscitating an acutely ill infant (SGY2) • • • 4 Neonatal Jaundice Newborn Pediatric Health Supervision • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Biliary atresia TORCH infections Neonatal hepatitis Sepsis Breast feeding jaundice Breast milk jaundice Physiologic jaundice Birth trauma/bruising Isoimmune/hemolysis Kernicterus Prematurity Birth asphyxia Congenital infections Respiratory distress Neonatal sepsis Large and small for gestational age Developmental dysplasia of the hip Undescended testes Ambiguous genitalia Absent red reflex Vitamin K deficiency Hypotonia Neonatal transition Trisomy 21 Fetal alcohol spectrum disorder Abnormal newborn screen Hypotonia Nutrition Growth parameters Hypertension Healthy active living Normal development Immunizations Anticipatory guidance Injury prevention Vision and hearing Dental health Discipline / Parenting Sleep issues SIDS Crying / Colic Sexual development / health • • • • • • • • • • • • • • • • • • • • • • • • Describe the necessary components of a complete perinatal history Discuss the complications of premature birth Describe the etiology and effects of birth asphyxia Describe the purpose of neonatal screening and be aware of the Ontario newborn screening program Discuss the transition from intrauterine to extrauterine environment with respect to: Temperature regulation Cardiac / respiratory physiology Glucose regulation Initiation of feeding Describe the nutritional requirements for growth and maintenance of health for infants, children and adolescents Compare breast and formula feeding Identify risk factors for pediatric hypertension Differentiate between primary and secondary hypertension Counsel a patient / family on the components and benefits of a healthy active lifestyle Describe how vaccines work and the disease they prevent Summarize the benefits and contraindications of immunizations Describe the concept of anticipatory guidance and potential topics for discussion from birth to adolescents Describe the epidemiology of childhood injury Describe age-related measures to reduce injury in the pediatric population Identify risk factors for hearing and vision impairment Describe the indications for hearing and vision screening in healthy and at risk children Describe the timing of eruption of the primary and permanent teeth Describe the epidemiology, etiology and prevention of dental caries Describe strategies for appropriate and effective discipline 5 • • • • • • Pallor (anemia) Rash Respiratory Distress / Cough Seizure / Paroxysmal event • • • • • Iron deficiency Hemolysis Inherited hemoglobinopathies (sickle cell anemia and thalassemia) Leukemia • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Cellulitis Varicella Atopic dermatitis Diaper dermatitis Viral exanthems Scarlet fever Scabies Acne Impetigo Seborrhea Urticaria Drug Eruption Pneumonia Bronchiolitis Asthma Cystic fibrosis Pertussis Croup Foreign body Epiglottitis Tracheitis Congestive heart failure Anaphylaxis Febrile vs. non-febrile seizure General vs. focal seizure Status epilepticus ALTE Syncope Breath-holding spell • • • • • • • • • • Describe sleep physiology and stages, sleep needs for different age groups, and best practices for sleep hygiene List risk factors for and strategies that decrease the risk of Sudden Infant Death Describe the difference between normal and abnormal infant crying Describe the epidemiology, clinical manifestations, differential diagnosis and treatment of infant colic Describe how an adolescent history differs from a general pediatric history Describe the topics to be covered during an adolescent history (HEADDS) Differentiate between causes of anemia using the mean cell volume (SGY1) List common etiologies for microcytic, normocytic and macrocytic anemias (SGY1) Describe an approach to anemia diagnosis in a newborn baby (SGY1) List the ways to prevent iron deficiency anemia in infants (SGY2) Describe common infections characterized by fever and rash Describe an approach to respiratory arrest in children (SGY2) List the common causes of respiratory failure in children (SGY2) List complications of foreign body aspiration and ways this can be prevented (SGY1) List criteria for hospitalization of an infant with bronchiolitis (SGY1) Discuss the treatment plan and provide a prognosis for children with simple febrile seizures (SGY2) Describe the aspects of the history and physical examination that would support a diagnosis of meningitis in a child with a fever and seizure (SGY2) 6 Sore ear • • Otitis media Otitis externa • • • Sore / Red eye Sore throat / Sore mouth Urinary Complaints (polyuria / frequency / dysuria / hematuria) Vomiting • • • • • • • • • • • • • Periorbital cellulitis Orbital cellulites Conjunctivitis Pharyngitis Peritonsillar abscess Retropharyngeal cellulitis Stomatitis Oral thrush Diabetes / diabetic ketoacidosis Urinary tract infection Enuresis Post infectious glomerulonephritis Henoch-Schonlein purpura • • • • • Gastroesophageal reflux disease Pyloric stenosis Malrotation / volvulus Intussusception Gastroenteritis • • • Describe the pathophysiology, risk factors, clinical presentation and treatment of common diseases affecting the middle and external ear Name and classify pathogens that cause ear infections in children Describe the basic principles of pharmacology for antibiotic use and analgesia in ear infections Define vesicoureteral reflux and describe the different grades Compare and contrast the presenting signs and symptoms of an UTI in an infant, preschooler and school aged child (SGY1) Describe the natural history and a treatment approach for nocturnal enuresis (SGY1) Demonstrate competence with the following paediatric physical examination skills in addition to general physical examination skills: • • • • • • • • • • • • • • • Measure and interpret height, weight, head circumference (including plotting on growth curve and calculation of BMI) Measure and interpret vital signs Palpate for fontanels and suture lines Perform red reflex and cover-uncover test Perform otoscopy Inspect for dysmorphic features Elicit primitive reflexes Inspect for and describe common newborn skin rashes Assess for features that distinguish innocent from organic murmurs Perform infant hip examination Assess the lumbosacral spine for abnormalities Assess for scoliosis Palpate femoral pulses Examine external genitalia Assess for sexual maturity rating (Tanner staging) 7 Clinical Teaching Unit (CTU – Red & Blue Teams) Welcome to Paediatrics and the CTU! We hope the following will be useful in orienting you to our service: 1. CTU – Who We Are The clinical teaching units consist of two teams, CTU Red and CTU Blue. Each team has 1 senior paediatric resident (PGY3 or 4), 1-2 junior paediatric residents (PGY 1) and 2-3 clerks, along with a consultant paediatrician. CTU Red’s consultant is a General Academic Paediatrician and CTU Blue’s consultant is a General Community Paediatrician. Both teams care for paediatric patients admitted to the hospital who require acute care. While many of the children we see are previously healthy, we also see a number of patients who are medically complex and well known to our medical community. The paediatric wards are located on B6-100 (North tower, 6th floor) at the Victoria campus. We see patients admitted from the Paediatric Emergency Department (1st floor, D tower), the Paediatric Critical Care Unit, the Neonatal Intensive Care Unit, the delivery room, the 4th floor mother baby unit and patients transferred from outside hospitals requiring tertiary paediatric care. 2. Meeting Time and Place The team meets every morning at 8am in the CTU classroom for morning handover, located in room B6-362. This is where you can leave your belongings though valuables should never be left. You will need your hospital ID badge to access the secure door to get into the CTU Classroom. 3. Expectations and Responsibilities Your primary responsibility is to learn the core topics of paediatrics as defined by the clerkship learning objectives while on the service. Each clerk is routinely assigned 3-4 patients and is responsible for their care in conjunction with the senior resident. You are expected to know your patients, present your patients for morning rounds, formulate a plan of care and execute this with approval from your senior resident, along with the writing of daily progress notes. Your residents will review what is expected in a progress note with you. Each morning, after morning handover at 0900, you are expected to pre round on your patients (i.e. check blood work, vitals, fluid balance, weight gain, po intake, ventolin administration, etc.) and look briefly through the chart to see if anything pertinent happened to your patient overnight. You may also be assigned teaching topics to be presented to the rest of your team, either during morning report OR in the afternoons. While you are also responsible for your patient’s orders, all orders must be reviewed and co-signed by your junior or senior resident. All notes and orders must be signed with the name of the clerk followed by “Meds III”. 4. The Day’s Routine 0730 – 0800 – Clerk teaching from Monday to Thursday in B6-362, CTU Staff teaching on Fridays in B6-362 0800 – 0900 – Meeting B6-362 – morning handover from overnight team – issues and new admissions. 0900 – 0930 – Pre rounding on assigned patients. 0930 – 1200 – Bedside patient rounds. 1200 – 1300 – Paediatric lunchtime rounds – B6-361 in the paediatric classroom. 1300 – 1600 – Patient care, progress notes etc. 1600 – 1700 – Handover to senior resident. Update the patient list on the computer. 1700 – 0800 – On call. *NOTE handover usually occurs around 17:00, depending on how busy the team is. Please do not leave the hospital without touching base with your senior resident at Pager 17760 for CTU Red senior and 17703 for CTU Blue senior. 5. Teaching Topics There are a total of eight teaching topics that will be covered during your two week CTU rotation. Teaching will take place between 7:30 and 8:00 each morning (Monday-Friday) in B6-362. 8 Newborn exam (this will be covered on the first Monday of the rotation in the afternoon) Neonatal jaundice (differential diagnosis and treatment) Sepsis/Meningitis Fluids Asthma Febrile Neutropenia Failure to thrive Developmental assessment (generally done as bedside teaching) Pneumonia Additional topics are covered during new admissions presentations in the morning and during walk around rounds in the morning 6. Oral Case Presentation Guidelines You will be expected to present your patients that you admitted overnight during morning handover. The purpose of the case presentation is to concisely summarize four parts of your patient’s presentation: History Physical exam Laboratory results Clinical reasoning – your understanding of the findings Basic Structure: Identifying information / chief complaint History of present illness Other active medical problems, medications, allergies, immunizations Physical exam – general assessment (well vs. toxic etc.), assessment of growth and key findings only Investigations (lab and imaging) Assessment and plan Important points to remember: This is a summary and should be between 3 and 5 minutes. The purpose is not to present all information gathered but rather the pertinent positives and negatives. This is a skill that takes time to learn. The oral presentation should be delivered from memory with only intermittent referral to your notes. You should try to maintain eye contact with your listeners during the presentation. The oral case presentation is different from the written presentation in that the written presentation contains all the facts, but the oral presentation contains only those facts that are essential for understanding the reason for admission, differential diagnosis and management plan. You will be expected to present your patients every morning while on bedside patient rounds. You will be expected to follow a specific format as follows: Identification 1 sentence summary of why the patient is in hospital Current Issues Plan Information you should know about your patient (if applicable) when asked: Vital signs Fluid balance/urine output (if performed by nurse) Weight gain/loss, particularly in infants TFI (total fluid intake) – most important in infants/renal patients How often is child receiving PRN medications e.g. ventolin if prescribed PO intake Any fever (how high) 9 Example: Lisa Smith is a 2-month-old girl presenting with a 2-day history of fever, and admitted for a full septic work up. Current issues include: Follow up of full septic work-up results Likely diagnosis of UTI given urine R/M findings. Plan today is to follow up blood, CSF and urine cultures. Will narrow antibiotic coverage once sensitivities are available. Renal U/S and VCUG will be arranged if urine culture is positive. 7. On Call You will be on call with a paediatric resident from 1700-0800. On weekends, the clerks on call are to arrive at the hospital at 0900 for sign-in rounds. You will be responsible for admissions to the floor and will be expected to assess the patients, take their history, do the physical exam and come up with a plan with admission orders. The clinical case and orders will be reviewed with the resident on call. This can be a busy service so be prepared to be awake most of the night. Faye’s Cafeteria is located on D-3 and is open 24 hours from Sunday at 0630 to Friday at 2100 hours. Saturday hours are 0630-2000 hours. There is a fridge located in the hallway across from the CTU classroom. In the morning, it is the on call clerk’s job to pre round on his/her assigned patients as well as those whom he/she has admitted overnight. The on call clerk is also responsible for updating the patient list with any newly admitted patients, as well as printing the list for the team in the morning. If there are special reasons that you need to switch a call, you are required to arrange a switch with one of your colleagues and email Suzanne Belanger with your request. All shift changes must be approved at least 3 days in advance. 8. Post Call Post call clerks are expected to see the more complex patients during rounds and complete handover to the team in the morning. They will be permitted to leave by 10am. Please do not go home post call until you have paged your senior resident and updated him/her on your patients. 9. Resources In the resident room there is a “CTU Clerk Education Binder”. In the binder are numerous articles and handouts based on the paediatric clerkship learning objectives. Please feel free to photocopy what you require, but return the binder so all can use it. 10. Have FUN!!! Self-Explanatory. Do not be afraid to interact with the children. They will be your most influential teachers!! If you have any questions or concerns, please don’t hesitate to ask the residents on your team. Remember… you are not expected to already know paediatric medicine. Rather, it is our job to teach it to you. However, you are expected to work hard while on this service. Make sure you know your patients, read around the cases and be on time. The rest will take care of itself. 10 CTU - Discharge Summary Dictation Template All patients who: 1. were admitted for seven or more days, and/or 2. had been admitted to the PCCU (Paediatric Critical Care Unit), and/or 3. had a complex condition or complicated course in hospital require a dictated (or typed) discharge summary. 1. Required initial information: Your name and position, most responsible physician (MRP) on the day of discharge, patient’s first and last name, PIN, who should receive this discharge summary (the referring physician if one is known, the paediatrician or family physician of the patient (if not the referring physician), and other consultants who are going to see the patient in follow-up. Example: “This is John Smith, clinical clerk for Dr. X, dictating on patient Get me Out of Here, PIN 00000000. Please forward copies to Dr. Y, family physician in London, Dr. Z, Paediatrician in London.” 2. Most Responsible Diagnosis: Diagnosis primarily responsible for the patient’s current admission and relevant other diagnoses. 3. History of present illness: Essential history of chief complaint as given by patient and/or care providers. This should be a brief, concise summary of the relevant information from the time the symptoms started and up to the arrival at the Emergency Department. In children with a chronic disease of the organ system now acutely affected include a one- or two-line summary of the underlying condition. Do not describe other chronic issues here (see point 4.). Example: “Sam X is a 9-month old boy with chronic lung disease secondary to prematurity (27 weeks of gestation) on 0.5l of oxygen at home. He presented to our Emergency Department on January 3, 2012, with a 2-day history of increasing cough, increasing oxygen requirements (from the usual 0.5l to 2l on the day of presentation) and work of breathing, fatigue, and fever up to 38.9ºC.“ 4. Additional problems / relevant past medical history List other relevant medical issues not primarily responsible for the admission in brief. For children with multiple and/or chronic medical problems state health care provider following the child. Example: “- Prematurity: Born at 27+2 weeks of gestation by spontaneous vaginal delivery, Apgar’s at 1 and 5 minutes were 2 and 5. The baby had a complex postnatal history including 52 days of mechanical ventilation and a total stay of 13 weeks in the Neonatal Intensive Care Unit. Please see NICU discharge summary for details. Sam’s development is followed by Dr. A, Thames Valley Children Centre London. - Seizure disorder: Seizures controlled with Phenobarbital, last seizure October 2011, followed by Dr. B, Paediatric Neurology, Children’s Hospital London.” 5. Clinical findings: State abnormal clinical findings on admission. Negative findings should only be mentioned if clinically relevant to the case. 6. Investigations / Interventions List relevant investigations and interventions performed. 7. Course in hospital: Provide a concise summary of the management and course in hospital. If the patient had a PCCU or NICU admission briefly summarize the key aspects (not a day-by-day narrative) of this part of the admission first in a separate paragraph. 11 8. Medications: List current home medications on admission and, if applicable state any changes made to them. List all new (discharge) medications. Example: Current medications: - Spironolactone 7.5 mg po q12h (Increased from 5 mg po q12h) New medications: - Cefuroxime 110 mg po BID 9. Discharge plan and followup: List treatments (include time line) and follow-up (include specifics of appointments). Example: - Cefuroxime 110 mg po BID until January 10th, 2012 - Follow-up with Dr. Y on Monday, January 12th 2012, at 9:00am 10. Closing: Example: Thank you very much for your referral. It has been a pleasure being involved in the care of this patient. 12 Emergency In the Paediatric Emergency Department you will perform the initial assessment of patients under the direct supervision of an attending paediatrician. You will have ample opportunity to evaluate and treat a wide variety of common paediatric complaints. Utilize this time to develop your physical examination skills and cultivate the skills pertinent to the examination of children. You will be expected to develop a differential diagnosis and management plan for common ambulatory problems. You are expected to complete 8 shifts during your two-week block in the Emergency Department. In order to allow yourself time to read, rest and attend teaching sessions, you may only work 5 shifts per week. Please note that all cases are to be reviewed and care completed or signed-over before leaving from your shift. Due to the nature of emergency medicine, this follow-up care may mean that you leave considerably later than the time your shift is scheduled to end. Please allow time in your schedule to accommodate this "over-time" work. At the completion of each shift, please ask the attending physician(s) to complete your assessment form. Please ensure that the assessment form is given to the staff at least one hour prior to the end of the shift to allow the staff adequate time to fill it out. This is a wonderful opportunity to receive feedback on a daily basis. Please note that ALL changes in the shift schedule must be approved by Suzanne Belanger at least three days prior to the scheduled shift(s). Family Centred Care in the Emergency Department Family-Centred Care (FCC): An approach to children’s health care that recognizes and respects the central role of the family in a child’s life, and encourages collaboration among the patient, family, and health care professionals. Family members are a critical part of our health care team. Health care professionals are the experts on health and disease. Families are the experts on their child and can offer essential information to enhance their child’s health care. Our guiding principles of familycentred care are: Respect: Parents and other family members deserve the same respect as other members of the team. Families’ choices are respected along with their values, beliefs and cultural backgrounds. Information Sharing: As important members of the team, families are entitled to timely, complete and unbiased information offered in a supportive way. This allows them to make informed decisions about their child’s care. Collaboration: Patients and families are active participants in the decisions made for their child. A family knows their child and the family’s strengths and circumstances. Professionals offer medical and other technical expertise. Together the best treatment plans can be created for the patient. Empowerment: Family-centred care programs and services build families’ confidence and ability to care for themselves and their child. Our Services Include: Paediatric Family Resource Centre, Family Advisory Council, Children & Youth Advisory Council, Family Handbook for New Patients, Patient Bill of Rights & Responsibilities. 13 Child Life Program A hospital visit can sometimes be a scary and unfamiliar experience for infants, children, youth and families, and often a source of tremendous stress and anxiety. The Child Life program strives to meet the psychosocial needs of children and youth while being in the hospital by helping them adjust to, and understand hospitalization, medical procedures, illness and injury. What Do Child Life Specialists Do? • Help alleviate the stress and anxiety that children and their families may encounter as a result of the hospitalization/medical experience. • Help children and their families understand their reactions and concerns to the hospital experience by providing accurate and honest information. • Explain medical experiences and what you may see, hear, smell, taste and feel while being in the hospital. • Create opportunities to explore and cope with “pretend” and/or actual medical equipment. This may increase your comfort level and familiarity with medical care. • Help families select procedures, tests and exams that are most helpful during your health care experiences. • Suggest coping techniques for procedures such as distraction, deep breathing and relaxation techniques. • May be present during medical procedures and provide information about medical events. • Offer support to family members such as siblings by helping them adjust to the hospital environment and understand health care experiences. • Provide opportunities for play. • Offer and adapt activities when children are in bed rest and/or in isolation. *** If you have an anxious, nervous, or scared child/family, or have ordered tests/procedures (e.g. blood work, IV start, scans, etc.), please utilize the service Child Life Specialists provide. You can ask the RN to ask the Child Life Specialist to see the patient/family, or you can page the Child Life Specialist at pager 17505 *** Tips for the Paediatric ER Here are a few tips from the nursing staff that will help make your experience in Paediatric Emergency Department a unique and enjoyable one. Communication • Try and remember to introduce yourself to the nursing staff and feel free to ask our names as well if we don’t introduce ourselves • Ask the nurses questions if you need to know anything about the department or the patients – we are a great resource • Mention that you have written orders if the nurses are at the desk, even if you plan to place the chart in the order box • Use the blue order box to place orders that need attention • Our policy is to practice Family Centered Care. This means that families are often present for all procedures and they will play an active role in decision making regarding patient care. Documentation • You must document which attending you saw/reviewed the patient with. You cannot just circle the name on top of the chart • You must include your designation (R1, M3) after your name, and the time you saw the patient • Include a diagnosis at the bottom of the chart • Document discharge instructions on the back and the time you sent the patient home on the front bottom left corner of the chart • Please do NOT take nursing notes to the bedside or charting room unless absolutely necessary. It can be an infection control issue. If you do take them, please inform the nurse • When you make a referral to an off service you must document what time you spoke with them. There is a specific spot near the bottom of the chart for this. • At times you will see a green form attached to the chart. This is called a CHIRRP form and it is a questionnaire about childhood injury. Your responsibility is to complete the back of the form, while the families complete the front. 14 Patient Flow and Access • Beds A-F, Quiet Room, and sometimes ISOL are in Pod 1 • Beds G-J, Privates 1, 2, 3, 4 are in Pod 2 • PAC is the ambulatory care unit, with beds 1-5 and sometimes ISOL • Please wait for the red cross (+) on First Net to be removed before heading to the bedside • Return charts to their original desk and slot when you are not using them. If the patient is discharged, you may write D/C home and place the chart in the blue orders box • There are many discharge information sheets for families. Please become familiar with their locations and use them to help families understand d/c instructions. • There are also Asthma and Mental Health packages that contain important information for families. Please distribute upon discharge to help the families manage at home Charge Nurse Area • There is a computer and desk close to the attending area which has been designated the charge nurse area. Please do not sit there or use that computer. • As an alternative, there is the physician’s office and two workstations on wheels outside the physician’s office that are often available for your use. The Fridge / Freezer • This is supposed to be for patient food only. However, if you need to store parts of your lunch in the fridge and you can find room then please do so respectfully. Please take everything out by the end of your shift. • The food that the hospital supplies is for patient use only. Please do not help yourself to sandwiches and chocolate milk. • All popsicles are made in a peanut free facility! Research Studies • Our department participates in a number of clinical trials. Please familiarize yourself with the current studies in our department while you are here. You may contact Cindy Langford during the day for more information on which patients would be appropriate. There are also posters throughout the department listing study criteria 15 Rural Regional Paediatrics Chatham The Department of Paediatrics in the Chatham-Kent Health Alliance offers a rotation in General Community Paediatrics for third and fourth year students. These rotations can be for 4 or 6 weeks. We offer the opportunity of reviewing patients in the outpatient office, emergency department, labour/delivery and nursery, and the Children's Treatment Centre. On-call schedule is negotiable. You will be allowed use of a pager and given the choice of scheduled or unscheduled on-call. Most students chose to be available for educational and interesting cases and use the rest of their time for independent learning. Weekend on-call is similarly negotiable. Housing is arranged by Mary Peterson and our administration. There is an onsite gym available to you for a low cost which can be arranged through administration. The members of our department will offer exposure to a variety of clinical cases in areas of: Common Clinical Disorders in Office and Community Practice; Child Development; Behavioral and Learning Disorders; Mental Health; Emergency Care; Neonatal Disorders and Resuscitation; Diabetes; Common Development Disorders. Our clinical teaching is case oriented. You are able to schedule individual sessions with staff if you wish. We would be happy to answer any questions you may have on our program by contacting us. Contacts: Fannie Vavoulis Tel: 519-437-6143 Fax: 519-436-2635 Email: [email protected] Dr. Ian Johnston 202 King Street West Chatham, Ontario N7M 1E5 Tel: 519-358-1309 Email: [email protected] Dr. Wendy Edwards Dr. Pervez Faruqi Dr. Gary Tithecott [email protected] [email protected] [email protected] St. Thomas St. Thomas Elgin General Hospital is a medium sized full serviced community hospital. The Emergency Department handles about 38,000 visits a year averaging 2 to 3 life threatening events each day. As a general hospital, all manner of things present in ER which is staffed by Emergency specialists. All forms of surgery are performed with the exception of Neurology and Heart. There are 3 fully trained OB specialists who deliver about 850 infants per year. We keep mild to moderate cases of prematurity and RDS and have the capability of ventilating infants if need be. There is a 12 bed paediatric ward, paediatric outpatient area, and a small Neonatal ICU. Students are shared with the person on-call (one in four weeks) and students go to all four Paediatric offices in a defined rotation (10.00am to noon, and 1.00pm to 5.00pm) each day, but meet the paediatrician on- call each a.m. (8.00 to 8.30) to look after hospital cases. Once a week they would be expected to stay in hospital. Circumcisions are a frequent procedure and a number of students have become quite proficient. Other procedures can be learned depending on interest. It is hard to predict but the students see what a general paediatrician doing consulting work and primary care would see, without a lot of other students or residents in the way. 16 In general 70% of your time would be spent in an office setting and 30% at the hospital. The first day will involve getting a parking pass “free with a deposit that is returned”, free meal plan, registration and a tour of the facilities plus a rotation guide for the individual offices. St. Thomas-Elgin General Hospital, 189 Elm Street, P.O. Box 2007, St. Thomas, Ontario, N5P 3W2 Contacts: Dr. Margaret Bertoldi 426 Talbot Street St. Thomas, Ontario N5P 1B9 Tel: 519-637-3591 Email: [email protected] Dr. Tariq Ahmed Dr. Paul Kerr Dr. Joshua N’Dur [email protected] [email protected] [email protected] Sarnia Sarnia is a town of approximately 73, 000 people on the shores of Lake Huron. Blessed with some of the best summer festivals in Southwestern Ontario and miles of beautiful beaches, Sarnia has plenty to offer any student who wishes to do a rotation here. You are provided with accommodations in a hospital-maintained residence with other students, located across the street from the hospital. The house has cable TV, high-speed Internet access (please bring your own laptop), washer/drier, and full kitchen. Sarnia has 3 main preceptors, Dr. Tom Lacroix, Dr. Nash Rashed and Dr. Harleen Bhandal. Learning opportunities will be shared among the 3 paediatricians. There are opportunities to participate in Videoconferencing Rounds, Interdisciplinary Rounds, Journal Clubs, CME’s, and other opportunities as they arise. You will have some on call duties (one weekend during your stay and one or two nights per week). The calls are not inhouse. You will be directly involved with various community agencies including breastfeeding consultants, local health unit programs, Children’s Aid Society, a children’s mental health centre, and a children’s rehabilitation centre. Contacts: Dr. Nashed Rashed 104-704 Mara Street Point Edward, Ontario N7V 1X4 Tel: 519-344-7819 Fax: 519-344-2599 Email: [email protected] Dr. Tom Lacroix [email protected] Stratford Stratford is a city with population of 31,000. Stratford General Hospital is regional hospital which services a wider population of 100,000 - 150,000 and is the secondary referral hospital for the Huron Perth Hospital Alliance and surrounding hospitals. Outreach clinics are run in Seaforth, Listowel and Wingham. Clinical clerks are usually assigned to participate in as many outreach clinics as is possible during their rotation. You will spend time in each of the paediatrician’s offices, seeing a variety of outpatients for consultation and follow-up. You 17 will participate actively in the ward management of admitted paediatric patients. The clerk is expected to do histories and physical exams. Hands-on experience is encouraged for enthusiastic participants. We try to provide some experience in Neonatology as well as General Paediatrics. Deliveries are done from 33 weeks gestation onwards. Babies who require tertiary care are transferred to London. Even opportunities to do various procedures are there for those willing to try. On call expectation is 1 call per week, arranged to the trainee’s preference, but additional shifts are encouraged because there is no doubt more experience can be gained by seeing the emergencies that come in after regular hours. If the individual stays in Stratford, arrangements can be made for a more informal call arrangement. Stratford is a beautiful city, which is the home of the world famous Stratford Festival, lovely shopping downtown and wonderful restaurants and coffee shops. We’re quite proud of our brand new paediatric unit (August 2009), and beautiful new emergency, ICU, surgery and radiology departments, as of August 2010! We look forward to seeing you. Contacts: Dr. Kirsten Blaine, Chief of Paediatrics Jenny Trout Centre 342 Erie Street, Suite 113 Stratford, Ontario N5A 2N4 Tel: 519-272-2040 Email: [email protected] Dr. Ram Gobburu Dr. Carolina Montiveros Dr. Philip Squires Dr. Shamin Tejpar [email protected] [email protected] [email protected] [email protected] 18 Teaching Sessions Paediatric Peer Presentations Tuesdays from 12:00 – 1:30pm Location: B2-116 or E3-201 Children’s Hospital, LHSC - see below for additional information Paediatric Clerkship Lectures Thursdays from 1:00 – 4:00pm Location: B2-116, Children’s Hospital, LHSC - you will receive a lecture schedule for the block at orientation - attendance is mandatory and there will be a sign-in sheet - you will be asked to evaluate the lectures Resident Rounds Mondays, Tuesdays and Thursdays from 12:00 – 1:00pm Location: B6-361, Children’s Hospital, LHSC - attendance is voluntary, but strongly recommended Grand Rounds Wednesdays from 12:00 – 1:00pm Location: B2-119 (amphitheatre), Children’s Hospital, LHSC - attendance is voluntary, but strongly recommended Paediatric Clerkship Peer Presentations Tuesdays from 12:00 – 1:30pm Location: B2-116 or E3-201, Children’s Hospital, LHSC - you will be asked to present an assigned topic to your colleagues - the schedule and topic will be given to you at the orientation session - you are encouraged to conduct this presentation as an interactive session - a faculty member will be present to facilitate these sessions and provide feedback - attendance is mandatory and there will be a sign-in sheet You are required to complete one 12-15 minute presentation on an assigned topic. Please ensure that you stick to the time limit as there are four-five presentations per session. The topics will be presented to your colleagues and one faculty observer. Peer participation should be encouraged during your presentation. During the preparation of your topic it is important that appropriate resources are used. Where appropriate, evidence based publications should be utilized. Prior to your presentation please forward to Suzanne Belanger one reference (in the form of a PDF or Word Document) that relates to your topic. Useful references would include recent review articles, paediatric guideline statements (i.e. CPS/ AAP), etc. The references and presentations will be emailed to your colleagues to aid in exam preparation. Attendance Attendance at lectures is mandatory unless you are post-call from the CTU. Attendance at peer presentations is mandatory unless are you are post- call from the CTU, placed at CPRI, or placed in a rural regional site. If you miss a teaching session you will be required to complete an assignment. For any unexpected absences it is your responsibility to contact your attending or senior resident first thing in the morning. You must also notify Suzanne Belanger and Becky Bannerman by email. 19 Recommended Resources You are expected to use a wide variety of peer-reviewed resources. Below are some of the resources that are recommended for paediatrics. There are many paediatric textbooks available of varying length. The large textbooks include Nelson's, Avery's and Rudolph's. These texts are typically about 7kg. in weight and 2000 pages in length. These texts are, with some exceptions, excellent references, and the purchase of one of these texts should be considered (although not necessarily entertained at this stage of training) for those planning careers in family medicine or paediatrics. Required Essentials of Paediatrics, 6th edition Marcdante, Karen J. and Waldo E. Nelson Saunders/Elsever, 2011 Recommended First Exposure Paediatrics Gigante, Joseph McGraw-Hill Companies, 2006 Pediatric Clinical Skills, 4th edition Goldbloom, Richard B. Saunders/Elsever, 2011 Pediatrics for the Medical Student, 3rd edition Bernstein, Daniel and Shelov, Steven Walters Kluwer/Lipencott Williams and Wilkins, 2012 Year 1 & 2 Child Health Small Group materials Websites Canadian Paediatric Society: www.cps.ca American Academy of Paediatrics: www.aap.org Council on Medical Student Education in Paediatrics: www.comsep.org Health Canada: www.hc-sc.gc.ca EMedicine: www.emedicine.com UpToDate: www.uptodate.com 20 Assessments Clinical Assessments & Assessment Forms Your clinical evaluations will contribute significantly to your final grade. It is your responsibility to ensure that staff physicians and residents complete the forms. The forms are colour-coded: Green White Pink Blue Purple = Observed Patient Encounter = Emergency Department = Clinical Teaching Unit = Selective = Regional In the Emergency Department, please give your form to the staff physician with whom you reviewed the most patients during your shift in the last hour of the shift, before the shift ends, to ensure that it will be completed prior to the physician leaving the department. For CTU, Selective, and Rural Regional rotations, please give form(s) to the staff person before the last day of your rotation. All forms are to be filled out by faculty only, not residents. During the rotation you must complete two observed histories and two observed physical exams. The history and physical exam may be on the same patient. A minimum of two observations must be made by a faculty member, not a resident (i.e. both a history and a physical exam on one patient, or two separate patient observations of either a history or a physical exam). The other two observations may be made by a resident. You are encouraged to get one observation per week as it becomes very difficult to get them all at the end of the rotation. You are unable to finish the rotation until they are completed. All assessment forms must be given to Suzanne Belanger by the last Thursday of the Block PRIOR to the start of the final oral examination. Peer Review The Peer assessment form must be completed on One 45 prior to the last Thursday of the rotation. Completion of a peer assessment is a mandatory component of the rotation; however, please only evaluate the colleague(s) with whom you have worked directly. Mid-Rotation Assessment On Tuesday of week four each clerk will meet with either Dr. Joanne Grimmer or Dr. Eva Welisch to review all assessments completed to date, as well as your progress in completing the ED-2 objectives (yellow book). In addition, any concerns that might exist with the rotation to date will be addressed at this time. If you are completing four weeks of your paediatric block at a rural regional site you will complete your mid-rotation with your rural regional preceptor using the Clerkship Mid-Rotation Assessment form included in your orientation package. Rotation Feedback Session & Exit Interviews At 1:00 pm on the last Friday of your rotation Dr. Grimmer or Dr. Welisch will meet with you to review the examination scores, discuss the rotation, and discuss your assessments with each of you individually. You will also be asked to evaluate the rotation and your teachers at this time. 21 Final Summative Assessment Your evaluation will be based on 2 major components: • Clinical Assessments: − CTU, Selective, Rural Regional, Emergency Department and Observed Patient Encounters • Final Examinations: − 100 question Multiple Choice examination, 2 question Oral examination In addition, peer assessment forms, as well as attendance at mandatory teaching sessions and/or completion of assignments will be taken into account. Criteria for Successful Rotation Completion Your overall assessment for the Paediatric Clerkship rotation will be either “meets expectations” or “does not meet expectations”. In order to determine whether expectations are met for a given rotation, a review of the summarized documentation will be performed in order to ensure criteria for passing the rotation are fully achieved. Minimum criteria for passing the rotation is that a student “meets expectations” in a minimum of four of the six weeks plus receives a passing grade on the final examination (see below). For those who have received a “does not meet expectations” for a two week rotation or for one of the two weeks of CTU, their file will be reviewed carefully. Borderline performances during the other weeks, if they exist, will also be taken into consideration. Failure of one or two of the six weeks plus any concerns about performance during the other weeks may constitute a failure. The assessment form for CTU, selective and the rural regional rotations are the same. The evaluation is based on the seven UME competencies. It may not be possible for all seven competencies to be evaluated for all of the rotations throughout your paediatric block, but throughout the six weeks all of the competencies will be evaluated. Failure to “meet expectations” for any subcomponent of the Medical Expert or Professional competencies result in failure for that part of the rotation. Failure in two or more of the other categories results in failure for that part of the rotation. There is one assessment form all off eight shifts in Emergency Medicine. The eight shifts are evaluated separately. Please ensure that you have the faculty fill out the assessment form and return it to you after each shift. All shifts must be evaluated and signed by a faculty member, not a resident. A passing grade on the final examinations is also required to pass the rotation. The final examination score consists of a composite of the written and oral components of the examination process. A pass on the final exam is a minimum of at least 50% on each of the components plus an average of 60% for the two components combined. The MCQ exam is worth 70% of the composite mark and the oral exam 30%. Individuals not achieving a passing score on the examination will be given the opportunity to re-write the examination prior to completion of the final assessment. 22 Examination The examination will be conducted on the final Tuesday and Thursday of the block. On Tuesday you will have a multiple choice exam of 100 questions (2.5 hours). On Thursday the oral exam will take place. The questions are based on the learning objectives in the handbook. All exam questions are objective based and based on content from the following sources: • • • • • Nelson Essentials of Paediatrics Academic half-day lectures Child Health Small Group content (years 1 and 2) Peer presentations CTU morning teaching rounds Suzanne Belanger will contact you as to the time and location of the exam. The oral examination questions are an opportunity for you to practice an oral exam. You will be asked two questions from the following groups: inpatient, outpatient, and emergency. You will be asked to generate a differential diagnosis, discuss the relevant history, physical examination, investigations and management plan for the patient. You may be given further information from the examiner. The oral examination questions are listed here. Clinical clerks have found these questions to be a valuable resource and have used the questions in several ways: • • • • to prepare for the examination to focus their reading to address the objectives to generate discussions with staff physicians and residents You are encouraged to discuss these cases with faculty members, residents, and each other. 23 Oral Examination Questions In order to assess the patient describe: 1. Focused history 2. Focused physical exam 3. Investigations 4. Differential Diagnoses 5. Management 6. Causes 7. Complications Emergency 1. A 6-year-old boy is involved in a motor vehicle accident. He has a scalp laceration, a fractured left femur, and is stuporous. 2. You are a third year medical student on call for Paediatrics and are asked to assess a 10-year-old child who is presenting with an acute exacerbation of previously diagnosed asthma in the emergency department. 3. A 4-year-old patient presents to the Emergency Department with a history of fever and lethargy 4. A 3-year-old toddler is seen in the ER because of a fall onto a coffee table at home. The child has been previously well. The child had no loss of consciousness and has not vomited. On examination the child is bright, alert and in no distress. There is a small abrasion over the left temple, but a cursory physical assessment is otherwise normal. 5. A 2-year-old toddler is seen in the ER because of an episode of twitching and depressed level of consciousness. This came on abruptly and lasted about a minute. After this, the patient was drowsy but responsive and noted to be very hot. The patient is on no regular medications and has previously been well. 6. 1-year-old boy is brought to the emergency department by ambulance. He has a three-day history of vomiting and diarrhea. He is lethargic, mottled, and his capillary refill time is 4 seconds. His heart rate is 180, his respiratory rate is 30, and his blood pressure is 60/30. 7. A 3-year-old child presents to the Emergency Department with a history of difficulty breathing, low-grade fever and stridorous respirations for two days. 8. A 15-year-old young woman is found in the locker room of her high school in an unresponsive state. She is brought to the Emergency Department by ambulance, where she continues to be unresponsive to voice and stimulation. 9. You have been asked to see a 4-year-old child who has presented to the Emergency Department with a history of unexplained bruising. By report, the child has numerous bruises in different stages of evolution. 10. You are a third year medical student working in the Paediatric ER. A 1-week-old male is seen in the ER because of a fever of 39 degrees Celsius. Inpatient 1. A 3-week-old baby is admitted to the hospital because of conjugated hyperbilirubinemia. Physical exam reveals an icteric infant with a large firm liver 4 cm below the costal margin. 2. A 2-day-old baby is admitted to hospital because this child has not yet passed meconium. The parents are concerned. 3. A 4-year-old girl is admitted to hospital because she is unable to weight bear on her left leg.. 4. You have been called to the newborn nursery to see a one-day-old infant who is described by the nursing staff as having difficulty breathing. 5. A 16-year-old male patient presents with a history of polyurea, thirst and weight loss. 24 6. A 14-month-old child is seen in clinic with the complaint of being increasingly clumsy. The child was the product of an uneventful term pregnancy and a normal delivery and has been well until about a month ago. Over the past month, the parents describe the child as having increasing difficulty in walking, crawling and in handling objects. The child is said to fall to the left when walking. 7. You are asked to see a 14-month-old male brought in by his mother due to a concern of pallor. 8. A 6-year-old boy is admitted to hospital with a history of spontaneous bruising over the past 3 days. He has no significant past medical history. On physical examination, you find cervical lymphadenopathy, a palpable liver and spleen, and generalized purpura. 9. A 9-month-old baby is admitted to the hospital with failure to thrive. Please describe your approach to this patient. His growth parameters at 5 months of age were: Length = 60th percentile; Weight = 50th percentile; Head circumference = 50th percentile. Now, his growth parameters are: Length = 25th percentile; Weight = 5th percentile; Head circumference = 40th percentile. 10. A 14-month-old girl is admitted to hospital with severe burns to both soles of her feet. Her mother states that the child burned her feet while stepping into the bath 3 days ago. The child appears otherwise well, but does not seem to be comforted by her mother. Outpatient 1. An 8-year-old boy and his mother come to your office. The parents and the school are concerned with the child’s behaviour. The mother wonders if he could have attention deficit hyperactivity disorder and asks if he should be on medication. 2. A 5-year-old boy presents to your office with his father. The child has a long-standing history of constipation and has recently developed watery diarrhea. The child is otherwise well and is growing and developing normally. 3. An 18-month-old child is brought to your office with the complaint that the child has not yet begun to speak. 4. A 3-year-old patient is seen in the office with history of having blood in the urine for the past day. The patient has been well previously overall, although the child had a sore throat and low-grade fever two weeks ago. 5. A 14-year-old female is brought to your office because of a concern with respect to short stature. 6. You are a third year medical student on call for Paediatrics and you are asked to see a 4-week-old baby boy for the assessment of jaundice. 7. A 4-year-old child is seen for the assessment of fever and pain in the right ear for two days after a three-day history of URTI. 8. A 3-year-old child is seen for the assessment of fever, abdominal pain and dysuria for two days. 9. You have been asked to see a 12-year-old child in your office with a long history of asthma, which has been described as poorly controlled. 10. A 10-year-old child is seen in our office because of poor growth. The child was previously well but over the past year or so, has grown very slowly. The child also has had weeklong episodes of diarrhea associated with abdominal pain. 25 Department Of Paediatrics Faculty Chair/Chief Dr. G. Filler, Nephrology Faculty Academic Paediatric Medicine Dr. D. Bock Dr. T. Frewen Dr. T. VanHooren Cardiology Dr. L. Altamirano-Diaz Dr. K. Norozi Dr. H. Rosenberg Dr. E. Welisch Child Protection/Emergency Medicine Dr. D.W. Warren Clinical Pharmacology Dr. D. Matsui Dr. M.J. Rieder (+ Emergency Medicine) Community Paediatrics Dr. F.P. Gorodzinsky Dr. R.F. Lubell Dr. B. Lyttle Dr. M. Manchanda Dr. A. Mohammed Dr. R. Nasreen Dr. D. Pavri Dr. L. Stare Dr. M.J. Stoffman Critical Care Dr. J. Foster Dr. D. Fraser Dr. A. Kornecki Dr. A. Sarpal Dr. R. Singh Dr. J. Tijssen Developmental Paediatrics Dr. P. Frid (TVCC) Dr. J. McLean (CPRI & TVCC) Dr. C. Mitchell (CPRI) Dr. K. Rovis (CPRI) Emergency Medicine Dr. K. Forward Dr. K. Helleman Dr. G.I. Joubert Dr. J. Kilgar Dr. R. Lim Dr. E. Loubani Dr. T. Lynch Dr. S. Mehrotra Dr. A. Misir Dr. G. Mosdossy Dr. N. Poonai Dr. G. Sangha Endocrinology Dr. C. Clarson Dr. P. Gallego Dr. R. Stein Gastroenterology Dr. D. Ashok Dr. P. Atkison (+ Transplant) Dr. K. Bax Dr. J. Howard Genetics Dr. S. Goobie Dr. J.H. Jung Dr. C. Prasad Dr. V. Siu Haematology/Oncology Dr. A.E. Cairney Dr. P. Gibson Dr. L. Jardine Dr. S. Zelcer Dr. A. Zorzi Infectious Disease Dr. O. Hammerberg Dr. M. Salvadori Neurology Dr. C. Campbell Dr. S.D. Levin Dr. N. Prasad Neonatology/Perinatology Dr. K. Coughlin Dr. O. DaSilva Dr. V.K.M. Han Dr. C.F. Kenyon Dr. D. Lee Dr. H. Roukema Dr. D. Yuen Nephrology Dr. J. Grimmer Dr. A. Sharma Rheumatology & Academic Paediatric Medicine Dr. R. Berard Respirology Dr. A. Price Dr. D. Radhakrishnan Surgery Dr. D. Bartley (Orthopaedic) Dr. A. Bütter (General) Dr. T. Carey (Orthopaedic) Dr. L. Cooper (Ophthalmology) D. M. Husein (Otolaryngology) Dr. K. Leitch (Orthopaedic) Dr. D.L. MacRae (Otolaryngology) Dr. I. Makar (Ophthalmology) Dr. D. Matic (Plastics) Dr. A. Ranger (Neurosurgery) Dr. S. de Ribaupierre (Neurosurgery) Dr. L. Scott (General) 26 Rural Regional Paediatrics Chatham Dr. W. Edwards Dr. P. Faruqi Dr. I. Johnston Dr. G. Tithecott Owen Sound Dr. N. Kapalanga Sarnia Dr. T. Lacroix Dr. N. Rashed St. Thomas Dr. T. Ahmed Dr. M. Bertoldi Dr. P. Kerr Dr. J. Ndur Stratford Dr. K. Blaine Dr. C. Montiveros Dr. P. Squires Dr. S. Tejpar Windsor Dr. M. Adie Dr. H. Al-Tatari Dr. M. Awuku Dr. G. Bacheyie Dr. S. Burey Dr. S. W. Chow Dr. A. Deshpande Dr. H. Gangam Dr. E. Kassas Dr. H. Kazmie Dr. J. Liem Dr. L. Morgan Dr. C. Nwaesei Dr. R. Rahman Dr. M. Sottosanti Dr. A. Zaher 27 Paediatric House Staff On-Call Paging Pager # DAYS CTU-RED Senior Resident (R) 17760 15524 15534 Clerk PGY-4 Name CTU-BLUE Pager# E-mail Dr. Michael BISHARA 15538 [email protected] Dr. Michelle DANBY 14103 [email protected] Dr. Manpreet DOULLA 14564 [email protected] Dr. Cheryl FOO 15512 [email protected] Attending Physician 15526 Dr. Jennifer LI 15628 [email protected] Senior Resident (B) 17703 Dr. Tina PITTMAN 14106 [email protected] Clerk 15525 Dr. Samim AL QADHI 14417 [email protected] Dr. Sheena BELISLE 14547 [email protected] AFTER 1700 PGY-3 CTU CTU-1 Resident (will also page CTU-2) Clerk 17760 Dr. Mallory CHAVANNES 14604 [email protected] 15534 Dr. Breanna CHEN 18969 [email protected] Dr. Amaryllis FERRAND 15237 [email protected] 15595 (Arrest) Dr. Mireille GHARIB 15607 [email protected] Dr. Lara HART 15906 [email protected] Dr. Kayla LAM 15862 [email protected] Dr. Helen LEVIN 15895 [email protected] Dr. Emily MARCOTTE 19189 [email protected] Dr. Rohit NAGAR 19382 [email protected] Dr. Harshini SRISKANDA 15781 24 HOURS Senior Resident PCCU First Call 15515 (Arrest) [email protected] PGY-2 Second Call Dr. Natasha DATOO 19365 [email protected] Dr. Alisha GABRIEL Dr. Rania GOSSELINPAPADOPOULOS 19430 [email protected] 19474 [email protected] 18213 Dr. Elana HOCHSTADTER 19512 [email protected] 19967 Dr. Julie HUKUI 19518 [email protected] Dr. Elizabeth ROACH 19498 [email protected] Dr. Melissa ROSSONI 19158 [email protected] Dr. Filippe SCERBO 19034 [email protected] 19865 Dr. Amanda VIEIRA 19062 [email protected] 19972 Dr. Abeyat ZAMAN-HAQUE 19787 [email protected] 12824 (Arrest) Emergency Fellows: Dr. Natasha GILL ([email protected]) Dr. Amal AL_SHIBLI ([email protected]) PCCU Fellows: Dr. Farhana AL-OTHMANI ([email protected]) Dr. Yasser ALGARNI ([email protected]) Neonatology Fellows PGY-1 Dr. Eyhab BADER 13199 Dr. Richa AGNIHOTRI 19275 [email protected] Dr. Anita CHENG 15188 Dr. Beth Ellen BROWN 19131 [email protected] Dr. Jessica JAKOBCZYK 15910 Dr. Nita CHAUHAN 19487 [email protected] Dr. Ester RAI 13142 Dr. Becky CHEN 19010 [email protected] Dr. Soume BHATTACHARYA 19446 Dr. Chloe DAVIDSON 19342 [email protected] Dr. Renjini LALITHA 19279 Dr. Alia FIKRY 15875 [email protected] Dr. Aimann SURAK 10686 Dr. Shireen MARZOUK 19540 [email protected] Dr. Renne PANG 19414 [email protected] Dr. Victoria PILA 19476 [email protected] Dr. Amanda RAMSAROOP 19267 [email protected] Dr. David YUE 19003 [email protected] 28 Dictaphone Dictation System – London Hospitals City-Wide Prior to dictating all dictators must obtain a Dictation ID and Password Number from Health Records at ext. 35131. These numbers must remain confidential. This dictation system is provided to you for the clinical documentation for the LHSC patient record required for each hospital visit. Follow-up letters – i.e. to the Ministry of Transport, to whom it may concern, referral requests, etc. – are administrative correspondence and consequently are outside of Health Records responsibility for processing. To Access the System: • Dial: 66080 (onsite) or 519-646-6080 (offsite) • Enter your Dictation ID followed by the # key. • Enter the Hospital Site Code followed by the # key. 1 University 5 LRCP 2 Victoria 6 RMH-London 3 St. Joseph’s 7 RMH-St. Thomas 4 Parkwood • Enter the Work Type followed by the # key (see below) • Enter the Patient PIN (Medical Record Number) followed by the # key. • Enter 2 to dictate. • Enter 8 to end note and continue. Enter 5 to end and sign off the system. CITY-WIDE WORKTYPES 30 Preadmission Clinic Note 36 Delivery Report 31 History and Physical 37 Progress Note 32 Operative Report 38 Admission Note 33 Discharge Summary 39 Procedure Report 34 Consultation 40 Death Summary 35 Emergency Room Report 41 Telephone Correspondence University / Victoria (Helpline: 35131) LRCP (Helpline: 53248) 70 Radiation Treatment 80 Clinic Report 71 Letter 81 Adult Psychiatry Note 72 Social Work 82 Child / Adolescent Psychiatry 73 GYN Snap Shot 83 Women’s Health Clinic Note 74 Ovarian Progress 84 Trauma Resuscitation Note 75 LRCP Clinic Note 85 Trauma Clinic Note 86 Speech Language Pathology 87 Urgent Neurology Clinic Note 88 John H. Kreeft Headache Clinic 89 General Medicine Clinic Note 90 Geriatric Mental Health 91 TIA Clinic Note 92 Thoracic Surgery Clinic Note 93 In-hospital Transfer Note St. Joseph’s (Helpline: 65584) 42 SJH Clinic Note 43 HULC Clinic Note 44 OB/GYN Clinic Note Parkwood (Helpline: 42963) 50 Parkwood Clinic Note 51 Day Hospital Note 52 Psychiatry Note RMHC-London (Helpline: 47747) 60 Assessment Report 61 Review Board Summary 62 Miscellaneous Note 63 RMHC Clinic Note 29 Scope of Activities for Senior Medical Students at LHSC Policy A Senior Medical Student (formerly referred to as a Clinical Clerk) is an undergraduate medical student in year 3 or 4 of Medical School training, and not a physician under the regulated Health Professional Act (RHPA). The practice of medicine by Senior Medical Students at LHSC is to be under supervision of a licensed Physician in accordance with the regulations of the College of Physicians and Surgeons of Ontario. All orders, written by a Senior Medical Student, for the investigation or treatment of a patient, must be done under the supervision or direction of a Physician, and must be countersigned prior to the orders being processed and actioned. Senior Medical Students shall wear nametags clearly identifying them by name and as a “Senior Medical Student” and should not be addressed or introduced to patients as “Doctor”. It would then be the shared responsibility of student and supervisor to specifically introduce them as a medical student. Scope of Activities Guided by principles of graded responsibility, Senior Medical Students engaged in clinical activities may carry out controlled acts, according to the RHPA, under direct or remote supervision, depending upon the student’s level of training and competence. Documentation: by a Senior Medical Student of a patient’s history, physical examination, diagnosis and and/or progress notes, should be reviewed and countersigned, by the Supervising Physician. Orders: Orders are to be documented by the Senior Medical Student directly on the patient’s order sheet. The orders are to be clearly and legibly signed with the signature and name of the Senior Medical Student followed by the notation “Med III or Med IV for Dr. XXX”. A supervising physician will countersign the orders prior to implementation. Administration of Medications: It should be noted that Senior Medical Students are authorized to administer only those drugs, which can be administered by nurses on the general units. They are not permitted to administer any parenteral drug, which is classified as “Physician Only” or “Designated Nurse Only”, unless the Senior Medical Student is under the direct supervision of the Supervising Physician or has been authorized by the Supervising Physician to administer under remote supervision. Any question or concerns regarding the functions and responsibilities of Senior Medical Students should be addressed with the Physician supervising the student. Definitions “Supervising Physician” refers to a licensed physician who is delegated by their respective training program to supervise a medical student. He/she can be a Resident, the Most Responsible Physician or their delegate or a consulting physician holding privileges at the Hospital. Director, Medical Affairs IVP Medical Education & Medical Affairs Medical Advisory Committee 30