Pediatrics- Ward

Author: Andrea Reimer, Class of 2021

Content Reviewer: Gurkirat Kandola, Class of 2020

Case Objectives

1. Propose an approach to conducting a consult for pediatric patients

2. Perform a structured and concise consult presentation to an attending in Pediatrics

3. Demonstrate an approach writing admission orders in Pediatrics

4. Demonstrate an approach to writing SOAP notes for rounding on a Pediatrics patient

It’s your first week on your pediatrics rotation and you have just finished rounding as a team on NICU and the Peds ward. You have an opportunity to have a quick lunch then your attending tells you that there is a new consult coming in that is getting referred from a GPs office. They tell you it is a 3-year-old child coming in with a history of vomiting/diarrhea and new onset abdominal pain. You get the child’s name so you can review their PowerChart in preparation for the consult.

Tip

In Pediatrics, consults are usually seen in the assessment rooms on the Pediatrics floor, as opposed to in the Emergency room. Consults can come from the ER, a referral from a GPs office, or a transfer from another center. You often have time before the consult, either while you are waiting for the patient to arrive or while nursing is doing their assessment, to review the patient’s PowerChart and any past consults notes, recent labs, imaging, etc. that have been done. If patients have a more complicated PMHx, they have likely been seen by specialists at BC Children's, so you may have to go onto CareConnect to access their consult notes.

1. Propose an approach to conducting a consult for pediatric patients

Consult Note Tips

For pediatrics consults, it’s all about the detail. These consults often take 1-1.5 hours in the room with the family asking questions and doing the physical exam. It’s okay to take your time. The attendings are not expecting you to be super fast. They are more impressed with the level of organized details dn structure of your consults as opposed to how fast you can complete them. When it comes to kids, you never know which little detail may be the clue you need to solve the case. Pediatrics sees such a range of ages, from birth to 18 yo, so your histories will look fairly different depending on the child's age. Important points to remember:

For infants, get a comprehensive history of what babies do: eat, sleep, pee/poo + the birth history
For ALL teenages, do a HEEADSSS assessment, even if it does not seem related to the complaint. A social history is always relevant in Pediatrics. Additionally, always ask if this can be completed with just the patient (parent/ guardians outside).
In adolescent females complete a gynecological history.
All patients, regardless of age, get biometric marks. This includes height, weight and head circumference in infants. Check nursing notes prior to seeing the patient for these measurements.

Pediatric Consult Note

ID: 3 y.o previously healthy boy presentis with nausea, vomiting diarrhea and abdominal pain. He is accompanied by his mother (Jane) and father (Chris).

HPI

History mainly from parents, patient answers some questions with yes/no
Started feeling unwell 2 days ago, decreased activity from usual. Has had 4 episodes of emesis since yesterday and loose stool this AM.
Vomit- non-biliousmno blood, stomach contents, non-projectile, 4 episodes
Diarrhea- watery stool, no blood, no mucus, doesn’t seem to have pain with BMs, 3 bowel movements today, Was starting to toilet train, but is wearing diaper during these episodes. Passing flatus
Has seemed fatigued, just wants to lay on the couch, won’t play with sibling
Doesn’t want to eat anything, will drink apple juice and water, but less than normal. Usually eats and drinks very well.
Has been urinating normally, regular # wet diapers as usual. No blood
Tactile fever for one day, but no thermometer at home
No one else in the household is sick. Usually goes to daycare 3 days a week, there have been 2 other kids at daycare sick with a stomach bug. No recent travel.
This afternoon, he started to seem like he was starting to have a lot of abdominal pain, crying and holding his stomach. Hasn’t been this upset from abdominal pain before. Pain seems to be somewhat constant and getting worse, not associated with BMs

Review of Systems:

Denies changes in weight, fatigue, chills, changes in appetite. No changes in hearing or vision. Denies sore throat, nasal congestion, rhinorrhea, ear pain, or otorrhea. Denies any cough, difficulty breathing, chest pain, palpitations, dizziness, syncope. No complaints of dysuria, hematuria, or frequency. No joint or muscle pain/ swelling. No new rashes. No easy bleeding/bruising. No difficulties with balance, headaches, seizures, weakness.

PMHx/ PSHx: Was healthy before this, no major illness or hospitalizations previously.

Birth History: uncomplicated, planned pregnancy, with no risk factors, such as EtOH or drug use. Uneventful SVD, stayed in hospital for one day for routine postpartum care. Born at term, weighing 8 lbs 2 oz.

Medications: None (no herbal, OTC, vitamins)

Allergies: NKDA

Immunizations: up to date

FamHx

Mother (Jane)- 36, healthy, no regular medications
Father (Chris)- 40, take ramipril for HTN, otherwise healthy
Brother (Jake)- 8, healthy
No hx of consanguinity, infant/child death, genetic abnormalities in family
No Famhx of significant autoimmune conditions/ cancers.

Developmental History: Meeting all milestones appropriately, no parental concerns

Gross motor: rides tricycle and walks up stairs with alternating feet

Fine motor: feeds self without help, draws a circle

Language: able to state own age, 3-4 word sentences

Social:Associative play,

Cognitive: Toilet trained.

SocHx:

Mother- accountant, father- part-time construction business. Attends daycare 3 days a week. Have 1 dog at home. No substance use in the household. Financially stable.

Physical Exam

VS- BP: 100/75 HR:90 RR:20 O2: 99% on RA T: 37.9 (oral)
Height: 95cm (50th%) Weight:14.7kg (50-75th%)
Laying in bed holding abdomen- alert, answers questions with only yes/no, cooperative for physical exam
Head and Neck: Normal tympanic membrane bilaterally, no bulging/erythema/discharge. Normal oropharynx with no erythema/discharge. No rhinorrhea. No palpable lymph nodes. Mucus membranes somewhat dry
Cardio/Resp: Air entry equal bilaterally to bases of lungs. No crackles, wheezes or rubs. No thrills. Normal S1/S2, no EHS or murmurs. Capillary refill 2 seconds. Peripheral pulses strong, extremities warm.
GI: Abdomen non-distended, no rashes/bruising. Bowel sounds present. Non-peritonitic. Diffusely tender with no localization on palpation. No organomegaly. No CVA tenderness. DRE deferred at this time.
MSK/Derm: No swollen or tender joints, no rashes, mottling or petechiae.
Neuro: normal tone, 5/5 strength and normal sensation upper and lower limbs. 2/4 reflexes upper and lower limbs.

Investigations: None done yet.

Impression: 3 yo previously healthy and fully immunized male with a 2-day history of vomiting/diarrhea and new onset abdominal pain, presenting with a fever of 37.9.

DDX?

Plan: ?

Consult Note Tips

HPI: Document who is main historian (parent vs. patient). Important to be detailed and get the time course of events. Here you really want to understand what prompted them to come to the hospital/ what they are worried about (this will help you address these concerns).

Review of Systems: Find a template that works for you and ask all Peds patients a full review of systems. It will have to be tailored to suit the age of the patient. You should still be doing ROS for infants. Think of it as doing a head to toe assessment for all people.

Birth History: often you need to get from the parent. Should even be done in adolescent consults. Main components to include are:

Prenatal hx: complications, risk factors, GBS, GDM, HTN, Ultrasounds, genetic testing
Delivery hx: length, route
Postnatal hx: PPH, term/ preterm, NICU, resus, APGARs

Immunizations: If the child is not immunized, make sure to ask why?

FamHx: When reporting this, remember it is always from the perspective of the patient.

Developmental Hx: Get a chart with all of the milestones and carry it around with you to consults and ask milestones from the chart.

Physical Exam

Always plot the patients growth parameters on the growth curves to get their percentiles. These are in a filing cabinet in the nursing station (ask one of the nurses). If previous measurements are available, make sure to plot those.
A full head-to-toe exam is always essential in Pediatrics. If the exam is not directly related to the CC, it can be more of a screening exam of those systems (eg: MSK or neuro).

Investigations: Often when patients come from the ER, they will already have some basic lab work, and potentially imaging, available on PowerChart.

2. Discuss a differential for this pediatric patient.

DDx

Presenting your ddx is preceptor dependent: some like your top 3, some like top 5, some like your top 3 plus 3 that could kill you tonight.

Now that you have finished your history and physical exam and thought about your differential, you start to come up with a plan of what you want to do before you present to your attending. Based on the patient's symptoms, you feel that this is likely a case of gastroenteritis, but you want to make sure you aren’t missing a surgical abdomen or another GI related cause of his symptoms. Therefore you come up with the following plan:

Impression/Plan: 3 yo previously healthy and fully immunized male with a 2-day history of vomiting/diarrhea and new onset abdominal pain, presenting with a fever of 37.9. The differential for the patients symptoms include: gastroenteritis, a surgical abdomen- including appendicitis and intussusception, a UTI, and DKA. We will get some basic investigations, including a CBC, E7 and CRP. At this time, we will wait to perform blood cultures, pending the initial blood work. The patient does not appear clinically septic.

To rule out a surgical abdomen, we will get an abdominal X-ray. If this has any concerning features, we will consult General Surgery.
To rule out a UTI, we will get a UA and urine analysis.
To rule out DKA, we will get a blood glucose level.

With respect to the patient's fever, they are alert and oriented and do not have any neurological findings on exam to suggest meningitis- such as nuchal rigidity. We will not perform a lumbar puncture at this time. We will monitor the patient’s LOC during admission for any changes.

As the patient has not had significant oral intake, and sustained nausea and vomiting, we will start them on IV fluid rehydration and an anti-emetic.

Tip

For peds, the attendings love detail. That doesn’t mean you need to include every single little thing in your presentation. You want to include all of your important pertinent positives and negatives, and have more detail ready if they ask for it. It will take time and practice (all of third year and beyond), to begin to feel more confident with presenting to your attending and determining what to include and not to.

3. Demonstrate an approach writing admission orders in Pediatrics

Admission Orders

Admit To: Dr. Lee under the Pediatric Ward

Diagnosis: Gastroenteritis

Diet: NPO, re-assessed after surgical abdomen ruled out, then possible clear fluid as tolerated.

Activity: AAT

Vitals: Routine , call MD is UP < 0.5cc/kg/hr

Investigations

CBC, E7, CRP, stat blood glucose, UA, urine culture
Stat abdominal X-ray, req on chart

Input (Fluids): 50 cc/hr NS IV, reassess tomorrow

Medications:

Gravol 15mg IV/PO q6h PRN for nausea (1mg/kg/dose)
Tylenol 150mg PO q4h PRN for fever (10mg/kd/dose)

Admission Order Tips

Some of the pediatricians will write orders, while others will let you write them with help. Like all other specialties, the ADDAVID format works quite well here.

For fluids, make sure always to write when it should be reassessed, otherwise they may run continuously with no stop date.
For medications, check all dosing with the BC Childrens & Women’s Hospital Formulary (PedMed).

Now that you have some admission orders, you wait for some of the lab results to come back. The abdominal x-ray is quickly done and it does not show any free air or distended bowel, which makes the possibility of a surgical cause much less likely. The stat blood glucose was normal, ruling down DKA as a cause. Finally, the CBC, E7, CRP and UA come back, showing no sign of urine infection, and no elevated WBCs or CRP. The E7 and UA show that the patient is slightly dehydrated, so it is a good thing you started the fluids. You feel quite confident that this is likely just a case of gastroenteritis and the patient will have to stay a day or two to get some fluids, but should make a good recovery.

The following morning, you start your rounding on the pediatrics ward to see your new patient you admitted yesterday.

4. Demonstrate an approach to writing SOAP notes for rounding on a Pediatrics patient

CC3 Progress Note

ID: 3 y.o M with suspected gastroenteritis admitted for rehydration.

Vitals: VS- BP: 98/76 HR:95 RR:21 O2: 100% on RA T: 37.5 (oral)

S: N/V improved with Gravol. No more vomiting. 1 episode of diarrhea overnight- no blood/mucus. Abdo pain improved. Fever improved with Tylenol- Tmax:38.2. Slept well overnight and seems more alert and engaged this morning. Taking sips of water and juice now.

O: Abdomen non-distended, BS present, non-tender, no peritoneal signs. U/O 1.5 cc/hr. No new investigations.

A/P: 3 y.o admitted for gastroentertitis/ rehydration, condition improving with IV rehydration and antiemetic.

Switch to clear to full fluid diet today
Saline lock IV fluids when eating and drinking well
Disposition: monitor one more day, D/C tomorrow if well?

Progress Note Tips

Pediatrics uses unique vitals sheets different from any other ward- they take a couple days to get oriented to. They will include the vitals and feeding info (for infants). These are in black folders usually kept on top of the chart cart in the nursing station. The nurses are very helpful to orient you to where these are on the ward.

If the patient is asleep, do not wake them up. Document that they were asleep and write in whatever information you can from the nursing notes (with “as per nursing notes” added) OR check in on them after you have finished rounding on all your other patients. You won’t be faulted for not waking up a patient, but you will if you don’t document that you at least tried to round on them

Page updated

Google Sites

Report abuse