First Aid for the Pediatrics Clerkship, 3 Ed.

How to Succeed in the Pediatrics Clerkship

INTRODUCTION

This clinical study aid was designed in the tradition of the First Aid series of books. You will find that rather than simply preparing you for success on the clerkship exam, this resource will also help guide you in the clinical diagnosis and treatment of many of the problems seen by pediatricians. The content of the book is based on the objectives for medical students laid out by the Council on Medical Student Education in Pediatrics (COMSEP). Each of the chapters contains the major topics central to the practice of pediatrics and has been specifically designed for the third-year medical student learning level.

The content of the text is organized in the format similar to other texts in the First Aid series. Topics are listed by bold headings, and the “meat” of the topic provides essential information. The outside margins contain mnemonics, diagrams, summary or warning statements, and tips. Tips are categorized into typical scenarios Typical Scenario, exam tips Image, and ward tips Image.

The pediatric clerkship is unique among all the medical school rotations. Even if you are sure you do not want to be a pediatrician, it can be a very fun and rewarding experience. There are three key components to the rotation: (1) what to do on the wards, (2) what to do on outpatient, and (3) how to study for the exam.

ON THE WARDS . . .

Be on time. Most ward teams begin rounding around 8 A.M. If you are expected to “pre-round,” you should give yourself at least 15 minutes per patient that you are following to see the patient, look up any tests, and learn about the events that occurred overnight. Like all working professionals, you will face occasional obstacles to punctuality, but make sure this is occasional. When you first start a rotation, try to show up at least an extra 15 minutes early until you get the routine figured out. There may be “table rounds” followed by walking rounds, but the emphasis is patient-centered.

Find a way to keep your patient information organized and handy. By this rotation, you may have figured out the best way for you to track your patients, a miniature physical, medications, labs, test results, and daily progress. If not, ask around—other medical students or your interns can show you what works for them and may even make a copy for you of the template they use. We suggest index cards, a notebook, or a page-long template for each patient kept on a clipboard.

Dress in a professional manner. Even if the resident wears scrubs and the attending wears stiletto heels, you must dress in a professional, conservative manner. It would be appropriate to ask your resident what would be suitable for you to wear (it may not need to be a full suit and tie or the female equivalent). Wear a short white coat over your clothes unless discouraged.

Men should wear long pants, with cuffs covering the ankle, a long-sleeved, collared shirt, and a tie—no jeans, no sneakers, no short-sleeved shirts.

Women should wear long pants or a knee-length skirt and blouse or dressy sweater—no jeans, sneakers, heels greater than 1½ inches, or open-toed shoes.

Both men and women may wear scrubs during overnight call. Do not make this your uniform.

Act in a pleasant manner. Inpatient rotations can be difficult, stressful, and tiring. Smooth out your experience by being nice to be around. Smile a lot and learn everyone’s name. If you do not understand or disagree with a treatment plan or diagnosis, do not “challenge.” Instead, say “I’m sorry, I don’t quite understand, could you please explain . . .” Be empathetic toward patients.

Be aware of the hierarchy. The way in which this will affect you will vary from hospital to hospital and team to team, but it is always present to some degree. In general, address your questions regarding ward functioning to interns or residents. Address your medical questions to residents, your senior, or the attending. Make an effort to be somewhat informed on your subject prior to asking attendings medical questions.

Address patients and staff in a respectful way. Address your pediatric patients by first name. Address their parents as Sir, Ma’am, or Mr., Mrs., or Miss. Do not address parents as “honey,” “sweetie,” and the like. Although you may feel these names are friendly, parents will think you have forgotten their name, that you are being inappropriately familiar, or both. Address all physicians as “doctor” unless told otherwise. Nurses, technicians, and other staff are indispensable and can teach you a lot. Please treat them respectfully.

Take responsibility for your patients. Know everything there is to know about your patients—their history, test results, details about their medical problem, and prognosis. Keep your intern or resident informed of new developments that he or she might not be aware of, and ask for any updates of which you might not be aware. Assist the team in developing a plan, and speak to radiology, consultants, and family. Never give bad news to patients or family members without the assistance of your supervising resident or attending.

Respect patients’ rights.

Image All patients have the right to have their personal medical information kept private. This means do not discuss the patient’s information with family members without that patient’s consent, and do not discuss any patient in hallways, elevators, or cafeterias.

Image All patients have the right to refuse treatment. This means they can refuse treatment by a specific individual (e.g., you, the medical student) or of a specific type (e.g., no nasogastric tube). Patients can even refuse lifesaving treatment. The only exceptions to this rule are patients who are deemed to not have the capacity to make decisions or understand situations, in which case a health care proxy should be sought, and patients who are suicidal or homicidal.

Image All patients should be informed of the right to seek advanced directives on admission (particularly DNR/DNI orders). Often, this is done in a booklet by the admissions staff. If your patient is chronically ill or has a life-threatening illness, address the subject of advanced directives. The most effective way to handle this is to address this issue with every patient. This will help to avoid awkward conversations, even with less ill patients, because you can honestly tell them that you ask these questions of all your patients. These issues are particularly imminent with critically ill patients; however, the unexpected can happen with any patient.

Volunteer. Be self-propelled, self-motivated. Volunteer to help with a procedure or a difficult task. Volunteer to give a 20-minute talk on a topic of your choice. Volunteer to take additional patients. Volunteer to stay late. Bring in relevant articles regarding patients and their issues—this shows your enthusiasm, your curiosity, your outside reading, and your interest in evidence-based medicine.

Be a team player. Help other medical students with their tasks; teach them information you have learned. Support your supervising intern or resident whenever possible. Never steal the spotlight, steal a procedure, or make a fellow medical student or resident look bad.

Be prepared. Always have medical tools (stethoscope, reflex hammer, penlight, measuring tape), medical tape, pocket references often electronic these days, patient information, a small toy for distraction/gaze tracking, and stickers for rewards readily available. That way you will have what you need when you need it, and possibly more importantly, you will have what someone else needs when they are looking for it! The key is to have the necessary items with you without looking like you can barely haul around your heavy white coat.

Be honest. If you don’t understand, don’t know, or didn’t do it, make sure you always say that. Never say or document information that is false (a common example: “bowel sounds normal” when you did not listen).

Present patient information in an organized manner. The presentation of a new patient will be much more thorough than the update given at rounds every morning. Vital information that should be included in a presentation differs by age group. Always begin with a succinct chief complaint—always a symptom, not a diagnosis (e.g., “wheezing,” not “asthma”)—and its duration. The next line should include identifiers (age, sex) and important diagnoses carried (e.g., this is where you could state “known asthmatic” or other important information in a wheezer).

Here is a template for the “bullet” presentation for inpatients the days subsequent to admission:

This is a [age] year old [gender] with a history of [major/pertinent history such as asthma, prematurity, etc. or otherwise healthy] who presented on [date] with [major symptoms, such as cough, fever, and chills], and was found to have [working diagnosis]. [Tests done] showed [results]. Yesterday/overnight the patient [state important changes, new plan, new tests, new medications]. This morning the patient feels [state the patient’s words], and the physical exam is significant for [state major findings]. Plan is [state plan].

Some patients have extensive histories. The whole history should be present in the admission note, but in a ward presentation it is often too much to absorb. In these cases it will be very much appreciated by your team if you can generate a good summary that maintains an accurate picture of the patient. This usually takes some thought, but it is worth it.

How to Present a Chest Radiograph (CXR)

Always take time to look at each of your patients’ radiographs; don’t just rely on the report. It is good clinical practice and your attending will likely ask you if you did. Plus, it will help you look like a star on rounds if you have seen the film before.

Image First, confirm that the CXR belongs to your patient and is the most recent one.

Image If possible, compare to a previous film.

Then, present in a systematic manner:

1. Technique

Rotation, anteroposterior (AP) or posteroanterior (PA), penetration, inspiratory effort (number of ribs visible in lungfields).

2. Bony structures

Look for rib, clavicle, scapula, and sternum fractures.

3. Airway

Look at the glottal area (steeple sign, thumbprint, foreign body, etc.), as well as for tracheal deviation, pneumothorax, pneumomediastinum.

4. Pleural space

Look for fluid collections, which can represent hemothorax, chylothorax, pleural effusion.

5. Lung parenchyma

Look for infiltrates and consolidations. These can represent pneumonia, pulmonary contusions, hematoma, or aspiration. The location of an infiltrate can provide a clue to the location of a pneumonia:

Image Obscured right (R) costophrenic angle = right lower lobe

Image Obscured left (L) costophrenic angle = left lower lobe

Image Obscured R heart border = right middle lobe

Image Obscured L heart border = left upper lobe

6. Mediastinum

Image Look at size of mediastinum—a widened one (> 8 cm) suggests aortic rupture.

Image Look for enlarged cardiac silhouette (> ½ thoracic width at base of heart), which may represent congestive heart failure (CHF), cardiomyopathy, hemopericardium, or pneumopericardium.

7. Diaphragm

Image Look for free air under the diaphragm (suggests perforation).

Image Look for stomach, bowel, or NG tube above diaphragm (suggests diaphragmatic rupture).

8. Tubes and lines

Image Identify all tubes and lines.

Image An endotracheal tube should be 2 cm above the carina. A common mistake is right mainstem bronchus intubation.

Image A chest tube (including the most proximal hole) should be in the pleural space (not in the lung parenchyma).

Image An NGT should be in the stomach and uncoiled.

Image The tip of a central venous catheter (central line) should be in the superior vena cava (not in the right atrium).

Image The tip of a Swan–Ganz catheter should be in the pulmonary artery.

Image The tip of a transvenous pacemaker should be in the right atrium.

A sample CXR presentation may sound like:

This is the CXR of [child’s name]. The film is an AP view with good inspiratory effort. There is an isolated fracture of the 8th rib on the right. There is no tracheal deviation or mediastinal shift. There is no pneumo- or hemothorax. The cardiac silhouette appears to be of normal size. The diaphragm and heart borders on both sides are clear, no infiltrates are noted. There is a central venous catheter present, the tip of which is in the superior vena cava. This shows improvement over the CXR from [number of days ago] as the right lower lobe infiltrate is no longer present.

How to Present an Electrocardiogram (ECG)

See chapter on cardiovascular disease for specific rhythms.

Image First, confirm that the ECG belongs to your patient and is most recent one.

Image If possible, compare to a previous tracing.

Then, present in a systematic manner:

1. Rate (see Figure 1-1)

“The rate is [number of] beats per minute.”

Image The ECG paper is scored so that one big box is .20 seconds. These big boxes consist of five little boxes, each of which are .04 seconds.

Image A quick way to calculate rate when the rhythm is regular is the mantra: 300, 150, 100, 75, 60, 50 (= 300/# large boxes), which is measured as the number of large boxes between two QRS complexes. Therefore, a distance of one large box between two adjacent QRS complexes would be a rate of 300, while a distance of five large boxes between two adjacent QRS complexes would be a rate of 60.

Image For irregular rhythms, count the number of complexes that occur in a 6-second interval (30 large boxes) and multiply by 10 to get a rate in bpm.

2. Rhythm

“The rhythm is [sinus]/[atrial fibrillation]/[atrial flutter].”

Image If p waves are present in all leads, and upright in leads I & AVF, then the rhythm is sinus. Lack of p waves usually suggests an atrial rhythm. A ventricular rhythm (V Fib or V Tach) is an unstable one (could spell imminent death)—and you should be getting ready for advanced cardiac life support (ACLS).

3. Axis (see Figure 1-2 on page 7)

“The axis is [normal]/[deviated to the right]/[deviated to the left].”

Image If I and aVF are both upright or positive, then the axis is normal.

Image If I is upright and aVF is upside down, then there is left axis deviation (LAD).

Image If I is upside down and aVF is upright, then there is right axis deviation (RAD).

Image If I and aVF are both upside down or negative, then there is extreme RAD.

4. Intervals (see Figure 1-3 on page 7)

“The [PR]/[QRS] intervals are [normal]/[shortened]/[widened].”

Image Normal PR interval = .12–.20 seconds.

Image Short PR is associated with Wolff-Parkinson-White syndrome (WPW).

Image Long PR interval is associated with heart block of which there are three types:

Image First-degree block: PR interval >.20 seconds (one big box).

Image Second-degree (Wenckebach) block: PR interval lengthens progressively until a QRS is dropped.

Image Second-degree (Mobitz) block: PR interval is constant, but one QRS is dropped at a fixed interval.

Image

FIGURE 1-1. ECG rate.

Image

FIGURE 1-2. ECG axes.

Image

FIGURE 1-3. ECG segments.

Image Third-degree block: Complete AV dissociation, prolonged presence is incompatible with life.

Image Normal QRS interval ≤.12 seconds.

Image Prolonged QRS is seen when the beat is initiated in the ventricle rather than the sinoatrial node, when there is a bundle branch block, and when the heart is artificially paced with longer QRS intervals. Prolonged QRS is also noted in tricyclic overdose and WPW.

Image

FIGURE 1-4. ECG waves.

5. Wave morphology (see Figure 1-4)

a. Ventricular hypertrophy

Image “There [is/is no] [left/right] [ventricular/atrial] hypertrophy.”

b. Atrial hypertrophy

Image Clue is presence of tall p waves.

c. Ischemic changes

Image “There [are/are no] S-T wave [depressions/elevations] or [flattened/inverted] T waves.” Presence of Q wave indicates an old infarct.

d. Bundle branch block (BBB)

Image “There [is/is no] [left/right] bundle branch block.”

Image Clues:

Image Presence of RSR’ wave in leads V1–V3 with ST depression and T wave inversion goes with RBBB.

Image Presence of notched R wave in leads I, aVL, and V4–V6 goes with LBBB.

ON OUTPATIENT

The ambulatory part of the pediatrics rotation consists of mainly two parts—focused histories and physicals for acute problems and well-child visits. In the general pediatrics clinic, you will see the common ailments of children, but don’t overlook the possibilty of less common ones. Usually, you will see the patient first, to take the history and do the physical exam. It is important to strike a balance between obtaining a thorough exam and not upsetting the child so much that the attending won’t be able to recheck any pertinent parts of it. For acute cases, present the patient distinctly, including an appropriate differential diagnosis and plan. In this section, be sure to include possible etiologies, such as specific bacteria, as well as a specific treatment (e.g., a particular antibiotic, dose, and course of treatment). For presentation of well-child visits, cover all the bases, but focus on the patients’ concerns and your findings. There are specific issues to discuss depending on the age of the child. Past history and development is important, but so is anticipatory guidance–prevention and expectations for what is to come. The goal is to be both efficient and thorough.

Pediatric History and Physical Exam

HISTORY

ID/CC: Age, sex, symptom, duration

HPI:

Symptoms—location, quality, quantity, aggravating and alleviating factors

Time course—onset, duration, frequency, change over time

Rx/Intervention—medications, medical help sought, other actions taken Exposures, ill contacts, travel

Current Health:

Nutrition—breast milk/formula/food, quantity, frequency, supplements, problems (poor suck/swallow, reflux)

Sleep—quantity, quality, disturbances (snoring, apnea, bedwetting, restlessness), intervention, wakes up refreshed

Elimination—bowel movement frequency/quality, urination frequency, problems, toilet training

Behavior—toward family, friends, discipline

Development—gross motor, fine motor, language, cognition, social/emotional

PMH:

Pregnancy (be sensitive to adoption issues)—gravida/para status, maternal age, duration, exposures (medications, alcohol, tobacco, drugs, infections, radiation); complications (bleeding, gestational diabetes, hypertension, etc.), occurred on contraception?, planned?, emotions regarding pregnancy, problems with past pregnancies

Labor and delivery—length of labor, rupture of membranes, fetal movement, medications, presentation/delivery, mode of delivery, assistance (forceps, vacuum), complications, Apgars, immediate breathe/cry, oxygen requirement/intubation and duration

Neonatal—birth height/weight, abnormalities/injuries, length of hospital stay, complications (respiratory distress, cyanosis, anemia, jaundice, seizures, anomalies, infections), behavior, maternal concerns

Infancy—temperament, feeding, family reactions to infant

Illnesses/hospitalizations/surgeries/accidents/injuries—dates, medications/interventions, impact on child/family—don’t forget circumcision

Medications—past (antibiotics, especially), present, reactions

Allergies—include reaction

Immunizations—up to date, reactions

Family history—relatives, ages, health problems, deaths (age/cause), miscarriages/stillbirths/deaths of infants or children

Social history—parents’ education and occupation, living arrangements, pets, water (city or well), lead exposure (old house, paint), smoke exposure, religion, finances, family dynamics, risk-taking behaviors, school/daycare, other caregivers

ROS:

General—fever, activity, growth

Head—trauma, size, shape

Eyes—erythema, drainage, acuity, tearing, trauma

Ears—infection, drainage, hearing

Nose—drainage, congestion, sneezing, bleeding, frequent colds

Mouth—eruption/condition of teeth, lesions, infection, odor

Throat—sore, tonsils, recurrent strep pharyngitis

Neck—stiff, lumps, tenderness

Respiratory—cough, wheeze, chest pain, pneumonia, retractions, apnea, stridor

Cardiovascular—murmur, exercise intolerance, diaphoresis, syncope

Gastrointestinal—appetite, constipation, diarrhea, poor suck, swallow, abdominal pain, jaundice, vomiting, change in bowel movements, blood, food intolerances

GU—urine output, stream, urgency, frequency, discharge, blood, fussy during menstruation, sexually active

Endocrine—polyuria/polydipsia/polyphagia, puberty, thyroid, growth/stature

Musculoskeletal—pain, swelling, redness, warmth, movement, trauma

Neurologic—headache, dizziness, convulsions, visual changes, loss of consciousness, gait, coordination, handedness

Skin—bruises, rash, itching, hair loss, color (cyanosis)

Lymph—swelling, redness, tender glands

PHYSICAL EXAM

General—smiling, playful, cooperative, irritable, lethargic, tired, hydration status

Vitals—temperature, heart rate, respiratory rate, blood pressure

Growth—weight, height, head circumference and percentiles, BMI if applicable

Skin—inspect, palpate, birthmarks, rash, jaundice, cyanosis

Hair—whorl, lanugo, Tanner stage

Head—anterior fontanelle, sutures

Eyes—redness, swelling, discharge, red reflex, strabismus, scleral icterus

Ears—tympanic membranes (DO LAST!)

Nose—patent nares, flaring nostrils

Mouth—teeth, palate, thrush

Throat—oropharynx (red, moist, injection, exudate)

Neck—range of motion, meningeal signs

Lymph—cervical, axillary, inguinal

Cardiovascular—heart rate, murmur, rub, pulses (central/peripheral; bilateral upper and lower extremities including femoral), perfusion/color

Respiratory—rate, retractions, grunting, crackles, wheezes

Abdomen—bowel sounds, distention, tenderness, hepatosplenomegaly, masses, umbilicus, rectal

Back—scoliosis, dimples

Musculoskeletal—joints—erythema, warmth, swelling tenderness, range of motion

Neurologic—gait, symmetric extremity movement, strength/tone/bulk, reflexes (age-appropriate and deep tendon reflexes), mentation, coordination

Genitalia—circumcision, testes, labia, hymen, Tanner staging

Note: The COMSEP website (http://comsep.org) has a video clip demonstrating the pediatric physical exam. It can be found under “curriculum” then “curriculum support resources.”

YOUR ROTATION GRADE

Usually, the clerkship grade is broken down into three or four components:

Image Inpatient evaluation: This includes evaluation of your ward time by residents and attendings and is based on your performance on the ward. Usually, this makes up about half your grade, and can be largely subjective.

Image Ambulatory evaluation: This includes your performance in clinic, including clinic notes and any procedures performed in the outpatient setting.

Image National Board of Medical Examiners (NBME) examination: This portion of the grade is anywhere from 20% to 50%, so performance on this multiple-choice test is vital to achieving honors in the clerkship.

Image Objective Structured Clinical Examination (OSCE): Some schools now include an OSCE as part of their clerkship evaluation. This is basically an exam that involves standardized patients and allows assessment of a student’s bedside manner and physical examination skills. This may comprise up to one fourth of a student’s grade.

HOW TO STUDY

Make a list of core material to learn. This list should reflect common symptoms, illnesses, and areas in which you have particular interest or in which you feel particularly weak. Do not try to learn every possible topic.

Symptoms

Image Fever

Image Failure to thrive

Image Sore throat

Image Wheezing

Image Vomiting

Image Diarrhea

Image Abdominal pain

Image Jaundice

Image Fluid and electrolyte imbalance

Image Seizures

The knowledge you need on the wards is the day-to-day management knowhow (though just about anything is game for pimping!). The knowledge you want by the end-of-rotation examination is the epidemiology, risk factors, pathophysiology, diagnosis, and treatment of major diseases seen in pediatrics.

As you see patients, note their major symptoms and diagnosis for review. Your reading on the symptom-based topics above should be done with a specific patient in mind. For example, if a patient comes in with diarrhea, read about common infectious causes of gastroenteritis and the differences between and complications of them, noninfectious causes, and dehydration in the review book that night.

Select your study material. We recommend:

Image This review book, First Aid for the Pediatrics Clerkship

Image A major pediatric textbook—Nelson’s Textbook of Pediatrics (also available on MD Consult) and its very good counterpart, Nelson’s Essentials

Image The Harriet Lane Handbook—the bible of pediatrics: medicine, medications, and lab values as they apply to children

Prepare a talk on a topic. You may be asked to give a small talk once or twice during your rotation. If not, you should volunteer! Feel free to choose a topic that is on your list; however, realize that the people who hear the lecture may consider this dull. The ideal topic is slightly uncommon but not rare, for example, Kawasaki disease. To prepare a talk on a topic, read about it in a major textbook and a review article not more than 2 years old. Then search online or in the library for recent developments or changes in treatment.

Procedures. You may have the opportunity to perform a couple of procedures on your pediatrics rotation. Be sure to volunteer to do them whenever you can, and at least actively observe if participation is not allowed. These may include:

Image Lumbar puncture

Image Intravenous line placement

Image Nasogastric tube placement

Image Venipuncture (blood draw)

Image Pulling central (and other) lines

Image Foley (urinary) catheter placement

Image Ankle–brachial index (ABI) measurement

Image Transillumination of scrotum

Image Intraosseous line placement

Image Transcranial doppler study

HOW TO PREPARE FOR THE CLINICAL CLERKSHIP EXAMINATION

If you have read about your core illnesses and core symptoms, you will know a great deal about pediatrics. It is difficult but vital to balance reading about your specific patients and covering all of the core topics of pediatrics. To study for the clerkship exam, we recommend:

2–3 weeks before exam: Read this entire review book, taking notes.

10 days before exam: Read the notes you took during the rotation on your core content list, and the corresponding review book sections.

5 days before exam: Read the entire review book, concentrating on lists and mnemonics.

2 days before exam: Exercise, eat well, skim the book, and go to bed early.

1 day before exam: Exercise, eat well, review your notes and the mnemonics, and go to bed on time. Do not have any caffeine after 2 P.M.

Other helpful studying strategies include:

Study with friends. Group studying can be very helpful. Other people may point out areas that you have not studied enough and may help you focus on the goal. If you tend to get distracted by other people in the room, limit this to less than half of your study time.

Study in a bright room. Find the room in your house or in your library that has the best, brightest light. This will help prevent you from falling asleep. If you don’t have a bright light, get a halogen desk lamp or a light that simulates sunlight (not a tanning lamp).

Eat light, balanced meals. Make sure your meals are balanced, with lean protein, fruits and vegetables, and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst of energy for 1 to 2 hours, but then you’ll drop.

Take practice exams. The point of practice exams is not so much the content that is contained in the questions, but the training of sitting still for 3 hours and trying to pick the best answer for each and every question.

Tips for answering questions. All questions are intended to have one best answer. When answering questions, follow these guidelines:

Read the answers first. For all questions longer than two sentences, reading the answers first can help you sift through the question for the key information.

Look for the words “EXCEPT, MOST, LEAST, NOT, BEST, WORST, TRUE, FALSE, CORRECT, INCORRECT, ALWAYS, and NEVER.” If you find one of these words, circle or underline it for later comparison with the answer.

Finally, remember—children are not just small adults. They present with a whole new set of medical and social issues. More than ever, you are treating families, not just individual patients.

POCKET CARDS FOR THE WARDS

The following “cards” contain information that is often helpful during the pediatrics rotation. We advise that you make a copy of these cards, cut them out, and carry them in your coat pocket when you are on the wards.

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