Download 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:
ƒ differential diagnosis
ƒ initial diagnostic investigations
ƒ 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.
ƒ
ƒ
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.
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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.
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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.
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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.
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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