Clerkship Ready: Pediatrics

The goal of the adolescent well visit is to empower the adolescent in starting to take ownership of their health with the support of their parent/caregiver and their health provider. There are thus specific ways in which the adolescent well visit differs from well visits for younger children. We will discuss how you can approach these visits, how to handle patient confidentiality, and how to ask those sensitive questions.

Before visit:

1. Review normal psychosocial development of adolescence
2. Review sexual maturity rating (SMR) (previously referred to as Tanner Staging) of adolescence 
3. Review past medical history, medications, vaccines, labs, prior concerns from previous visits, and their last well visit if available. 
4. Vital signs (including BP), height weight, BMI.
5. Any screening questionnaires (e.g., PHQ-9A)

During visit:

1. Introduce yourself; ask how they would like to be addressed
2. Review structure of visit, including genital exam and interviewing adolescent alone; importance of confidentiality
3. Direct questions to adolescent as much as possible
4. Concerns from adolescent/parent or from prior visits that require follow up or updates
5. Psychosocial screening: HEADSS (home, education/employment, activities, drugs, sexuality, suicide/depression/self-image, and safety) or SSHADESS (strength, school, home, activities, drugs/substance use, emotions/eating/depression, sexuality, and safety). NOTE: Some of this will be done during confidential interview. 
6. Nutrition: number of meals/snacks, dairy intake 
7. Sleep: nighttime and naps
8. Screen time: duration, type(s)
9. Dental: frequency of brushing, last seen by dentist
10. Menstrual history: Age of menarche, frequency, length of periods, heaviness of flow, symptoms associated with menses
11. Review medications, allergies, growth chart, vaccines
12. Confidential interview: any additional questions or concerns; Home, Drugs and substance use; Emotions, eating, and depression; Sexuality; Safety

Physical exam

1. Head to toe
2. Discuss acne
3. Need chaperone for breast and genital exam

Preparation for oral presentation 

About the Speaker:

Host: Serwa Ertl, MD – Serwa Ertl, MD is an Assistant Professor of Pediatrics specializing in Adolescent Medicine at UVA Health. She completed her residency at Connecticut Children's Medical Center and fellowship in adolescent medicine at Children's National Medical Center.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

This episode describes how to prepare for a newborn’s first outpatient visit after they have been discharged from the birth hospital, including the information that you need to obtain from the medical record before the visit, the topics you need to discuss during the visit, and how to approach the physical examination in a newborn.

Introduction

Socio-emotional state of parents

Before the visit, you should review

• Prenatal history
• Delivery history, gestational age
• Physical exam at time of birth
• Preventative treatments
• Course in newborn nursery or NICU
• Type of feeding
• Concerns for infection
• Bilirubin
• Screening tests

Newborn visit

• Parental questions and concerns
• Feeding history and any problems with feeding
• Elimination 
• Sleep and safe sleep
• Social history and parental support system
• Review of systems – irritability, fever, rashes. 

Normal newborn vital signs

Infant growth parameters and weight trajectory

Physical exam

• General
• Head size and shape
• Eyes – pupil shape, red light reflex, scleral icterus
• Cardiovascular – murmurs, capillary refill
• Respiratory
• Abdominal
• Genitourinary – testicles, hernias/hydroceles, circumcision, vaginal discharge
• Musculoskeletal-  clavicles, hip 
• Skin – jaundice, birthmarks, sacral dimples
• Neurological: tone, reflexes

Anticipatory guidance

• Fever
• Safe sleep
• Prevention of shaken baby syndrome
• Postpartum depression
• Appropriate feeding

Next follow up appointment depends on weight, bilirubin level

Resources/Links:

https://peditools.org/bili2022/ - resource for management of hyperbilirubinemia

Links:

https://peditools.org/bili2022/

About the Speaker:

Host: Augustin Casals, MD – Augustin Casals, MD completed his pediatric residency at the University of Virginia. He is now a practicing pediatrician in Los Angeles, California.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

In Pediatric Gastroenterology (or GI) clinic, you will see patients with a host of gastrointestinal, pancreatic, liver, and nutrition issues. This episode will discuss specific questions that you will want to cover in your history and the elements of a complete GI exam - which is a lot more than just an abdominal exam!

Peds GI clinic covers a host of gastrointestinal, pancreatic, liver and nutrition issues

-3yr fellowship after peds residency 

Before Clinic 

• Review what types of patients you will be seeing. It may be a mix of lots of issues, or just a liver transplant clinic. This will tell you what type of prep you should do (conditions to read up on, medications to review, etc) before the day of clinic.
• On the day of clinic, review expectations with the attending, fellow or resident physician. Do they want you to see patient independently and write notes, just shadow or somewhere inbetween. Review what questions they always want asked, what exams you should do alone vs with your whole team. Setting expectations before you start will set you up for success! 
• Questions: Pain, the PQRST mnemonic is helpful to better understand the pain
  • Provoked the pain
  • Quality of the pain
  • Radiating
  • Severity 
• Specific questions to ask in Peds GI: 
  • Does pain wakes the patient at night? 
  • how much school or other activities the Patient has missed because of symptoms? 
  • Does defecation or passage of gas alleviates pain? 
  • Any specific dietary changes already tried?
• Poop! understand the:
  • Quality of the stool
  • Size and caliber of the bowel movement (Use Bristol stool scale)
• GERD vs EoE  
• A complete GI exam– a lot more than the abdomen!

About the Speakers:

Host: Rachel Moon, MD – Rachel Moon, MD is the Harrison Distinguished Professor of Pediatrics at UVA Health Children's. She is an internationally recognized researcher in sudden unexpected infant death and chairs the AAP Task Force on SIDS. She is also the Chief of General Pediatrics at UVA.

Host: Jeremy Middleton, MD – Jeremy Middleton, MD is an Associate Professor of Pediatrics and Pediatric Gastroenterologist at UVA Health. He serves as the Pediatrics Clerkship Director and has expertise in children with intestinal failure and aerodigestive disorders.

Host: Shakun Gupta, MD – Shakun Gupta, MD is an Associate Professor of Pediatrics and Associate Clerkship Director at the University of Virginia. She completed her residency at Lurie Children's Hospital/Northwestern and joined UVA in 2014, where she practices general pediatrics and pediatric hospital medicine.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

This episode will prepare you for your first well child visit. In primary care, about half of a pediatrician's time will be spent in well child visits. We will talk about what you need to review before you walk into the patient's room, the elements of the history (diet, sleep, elimination, development, etc.) that you need to ask about in well child visits, tips to approaching the physical exam in children, and anticipatory guidance. Finally, we will provide an example of an oral presentation for a well child visit.

About the Speakers:

Host: Rachel Moon, MD – Rachel Moon, MD is the Harrison Distinguished Professor of Pediatrics at UVA Health Children's. She is an internationally recognized researcher in sudden unexpected infant death and chairs the AAP Task Force on SIDS. She is also the Chief of General Pediatrics at UVA.

Host: Jeremy Middleton, MD – Jeremy Middleton, MD is an Associate Professor of Pediatrics and Pediatric Gastroenterologist at UVA Health. He serves as the Pediatrics Clerkship Director and has expertise in children with intestinal failure and aerodigestive disorders.

Host: Shakun Gupta, MD – Shakun Gupta, MD is an Associate Professor of Pediatrics and Associate Clerkship Director at the University of Virginia. She completed her residency at Lurie Children's Hospital/Northwestern and joined UVA in 2014, where she practices general pediatrics and pediatric hospital medicine.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

This episode will prepare you to see well newborn babies in the newborn nursery on day 1. We will talk about the typical newborn stay, the information you need to gather to successfully give oral presentations on your patients, the newborn physical exam, and the tests and procedures commonly performed on all newborns.

• Nursery orientation: family expectations and goals of the healthcare team, expected length of stay
• History 
  • Maternal History:
    • Gs and Ps
    • Prenatal Care: prenatal labs and ultrasounds
    • Past Medical History & medications
    • Social situation/support
  • Baby History:
    • Gestational Age
    • Delivery type and why, resuscitation efforts and complications
    • Growth parameters
• The complete newborn exam: head to toe
• During the newborn stay:
  • Ins and Outs
  • Medications and vaccines
  • Routine screening labs and tests
  • Parental discharge education 
  • Discharge criteria and follow up

About the Speaker:

Host: Shakun Gupta, MD – Shakun Gupta, MD is an Associate Professor of Pediatrics and Associate Clerkship Director at the University of Virginia. She completed her residency at Lurie Children's Hospital/Northwestern and joined UVA in 2014, where she practices general pediatrics and pediatric hospital medicine.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

Pediatrics is different from any other rotation that you will do. Children are not just small adults. There is a huge range of ages and developmental stages. This episode will provide you with some general tips and tricks for all clerkships in general and the Pediatrics clerkship specifically, and essential resources that will help you to succeed in your clerkship.

Essential Resources

 Podcasts:

• Clerkship Ready-Pediatrics
• Charting Pediatrics - Weekly podcast with lots of bread-and-butter pediatrics discussed. 
• Pediatrics on Call - The most recent research and the newest policy updates from the American Academy of Pediatrics. 

Books:

• Red Book (also an app for AAP members) - the definitive source for pediatric infectious diseases. 
• Harriet Lane Handbook (also an app) - has drug doses, commonly used charts, and algorithms.  

Websites:

• Peditools for bilirubin 
• Uptodate
• CDC website is a great source for vaccine guidelines

Apps:

• PedsScripts App: specifically to work on illness scripts

General Tips and Tricks:

• Be Proactive
• Know what the expectations are. 
• Become familiar with the electronic medical record system. 
• Be Self-sufficient, but ask for help when appropriate. 
• Know when you should come in to round, who to pre-round on, and where to meet.  Pair up with an intern to pre-round.
• Ask for feedback.  

Pediatric-specific Tips and Tricks:

• Pediatrics is different from any other rotation. 
• Huge range of ages and developmental stages.
  • At every age, children act differently - and you need to adjust appropriately.
  • If you can, get as much of the history from the child, but you will likely need to supplement that with history from the parent or guardian. 
  • When you do your physical exam on younger children, have to adjust the order of exam  
  • Vital signs change with age. Look up or ask about what is a normal vital sign in the age you are seeing. 
  • Check weight, length/height and/or head circumference and report both percentiles and trends.
  • If an infant has been born prematurely, correct growth and development for gestational age. 
  • Fluids and medication are dosed per kilogram. 
• Family-centered rounds are a unique, important part of pediatrics. The goal is to get both the team and family up to date on the patient’s diagnosis and overall course, and to formulate a plan for the day together with the family.  
  • Brief summary and plan outside of the patient room. 
  • Invite family to participate. 
  • Conversational language with no medical jargon. 
  • Be concise and clear. 

About the Speakers:

Host: Rachel Moon, MD – Rachel Moon, MD is the Harrison Distinguished Professor of Pediatrics at UVA Health Children's. She is an internationally recognized researcher in sudden unexpected infant death and chairs the AAP Task Force on SIDS. She is also the Chief of General Pediatrics at UVA.

Host: Jeremy Middleton, MD – Jeremy Middleton, MD is an Associate Professor of Pediatrics and Pediatric Gastroenterologist at UVA Health. He serves as the Pediatrics Clerkship Director and has expertise in children with intestinal failure and aerodigestive disorders.

Host: Shakun Gupta, MD – Shakun Gupta, MD is an Associate Professor of Pediatrics and Associate Clerkship Director at the University of Virginia. She completed her residency at Lurie Children's Hospital/Northwestern and joined UVA in 2014, where she practices general pediatrics and pediatric hospital medicine.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.