Ambulatory Pediatric 101

Basic Clinical Skills

Yingshan Shi, MD

Lake Park Pediatrics

July, 2007

Ambulatory RotationAmbulatory Rotation

The time to learn how to The time to learn how to be a successful clinicianbe a successful clinician

5Ws and How5Ws and HowWhy, Where, Why, Where,

Who & Whom, Who & Whom, What & HowWhat & How

WhyWhy

AcademicAcademic

ClinicClinic

WhereWhere

Clinics Clinics Solo, GroupSolo, Group

Hospital Based Hospital Based

Univ. AffiliatedUniv. Affiliated

Who and WhomWho and Whom

Satisfy and Fit toSatisfy and Fit to

• Providers – team work Providers – team work

• Patients’ needs and Parents’ Patients’ needs and Parents’ wantwant

PatientsPatients

IndividualsIndividuals

Parents and FamiliesParents and Families

Communities Communities

Daycares and Schools Daycares and Schools

WhatWhat

Well Check-Well Check-UpUp

Sick VisitsSick Visits

How How

ConcernConcern

Basic clinic skills - SOAPBasic clinic skills - SOAP

Know what is normal and red Know what is normal and red flagflag

Education and counseling Education and counseling skillsskills

Right to the point Right to the point

Basic Clinic SkillsBasic Clinic Skills History IntakeHistory Intake

Use all your sensesUse all your senses

Vocal and non-vocalVocal and non-vocal

Evaluate patients and Evaluate patients and parents parents

Symptoms addressed Symptoms addressed

Detail and simplify Detail and simplify

History Intake - FeverHistory Intake - Fever

Fever 3 days and Max 102Fever 3 days and Max 102

Fever 3 days Fever 3 days

Day 1 101 at am 102 at pmDay 1 101 at am 102 at pm

Day 2 101 at am 101 at pmDay 2 101 at am 101 at pm

Day 3 100 at amDay 3 100 at am

History Intake - FeverHistory Intake - Fever

Fever 3 days and resolved for 1 dayFever 3 days and resolved for 1 day

Day 1 101 at am 102 at pmDay 1 101 at am 102 at pm

Day 2 101 at am 101 at pmDay 2 101 at am 101 at pm

Day 3 100 at am 99 at pmDay 3 100 at am 99 at pm

Day 4 98 at amDay 4 98 at am

Fever 3 days and resolved for 1 dayFever 3 days and resolved for 1 day

Max 102 on day1Max 102 on day1

History Intake - FeverHistory Intake - Fever

How longHow longHow high by days and timesHow high by days and timesAssociated SymptomsAssociated Symptoms

Sick contacts, travel, pets,Sick contacts, travel, pets,daycare and school attendants …daycare and school attendants …PFSIPFSI

History Intake - CoughHistory Intake - Cough

Cough 3 days Cough 3 days

Cough 3 days, dry and hash, Cough 3 days, dry and hash,

Getting worse Getting worse

Worsen over night Worsen over night

Waked up by coughing Waked up by coughing

History Intake - CoughHistory Intake - Cough

How longHow long

How it soundsHow it sounds

What time - day or nightWhat time - day or night

Getting better or worse Getting better or worse

Associated symptomsAssociated symptoms

PFSIPFSI

History Intake - VomitingHistory Intake - Vomiting

Vomiting 1 day or vomiting 3 times Vomiting 1 day or vomiting 3 times todaytoday

Vomiting 3 times todayVomiting 3 times today

11stst vomiting 12 hrs ago vomiting 12 hrs ago

22ndnd vomiting 5 hrs ago vomiting 5 hrs ago

Last vomiting 1 hrs ago after taking 4 Last vomiting 1 hrs ago after taking 4 oz milkoz milk

History Intake - VomitingHistory Intake - Vomiting

Vomiting 10 times todayVomiting 10 times today

Vomiting 10 times todayVomiting 10 times today

11stst vomiting 1 hrs ago vomiting 1 hrs ago

Last vomiting 5 minutes ago Last vomiting 5 minutes ago without drinking or eating solid without drinking or eating solid foodfood

History Intake for Sick History Intake for Sick Visits Visits SymptomsSymptoms

Activities and Appetites Activities and Appetites

Allergy and MedicationsAllergy and MedicationsPast, Family, and SocialPast, Family, and Social

Birth, Feeding, and ImmunizationBirth, Feeding, and Immunization

Sick ContactsSick ContactsDaycare and School AttendantDaycare and School Attendant

Pets Pets TravelTravel

Physical ExamPhysical Exam

• Well check-up:Well check-up: head to toes head to toes

• Sick visits:Sick visits: symptom symptom orientatedorientated

• Medical problem:Medical problem: following- following-upup

Physical Exam – Vital Physical Exam – Vital SignsSigns

Temperature – Fever Temperature – Fever

Axillary 99.5 °F Axillary 99.5 °F (37.5°C)(37.5°C)

Oral 99.5 °F Oral 99.5 °F (37.5°C)(37.5°C)

Rectal 100.4 °F (38°C)Rectal 100.4 °F (38°C)

Physical Exam – Vital Physical Exam – Vital Signs Signs

Nelson 16Nelson 16thth ed ed

Age Age Birth Birth 1-6y1-6y 10y10y

Heart Heart RateRate

100-180100-180 80-13080-130 70-11070-110

RespiratorRespiratoryy

RateRate

30-6030-60 20-3020-30 15-2015-20

BPBP

Sp/DpSp/Dp6mo6mo

105/65105/65105-110/105-110/

67-7067-70117/75117/75

Physical Exam – Vital Physical Exam – Vital Signs Signs

Nelson 16Nelson 16thth ed ed

Weight Weight Length/HeightLength/Height HCHC

PoundsPounds

At Birth 7At Birth 7

5mo 145mo 14

11mo 2111mo 21

1yr 221yr 22

>1y 5->1y 5-6lb/yr6lb/yr

Rule of 5Rule of 5

InchesInchesAt Birth 20At Birth 20

1yr 301yr 30

2-12y 2-12y 2.5/yr2.5/yr

Rule of Rule of 2.52.5

At Birth At Birth 34-34-35cm 35cm

0-3mo 0-3mo 2.0cm/mo2.0cm/mo

4-6mo 4-6mo 1.0cm/mo1.0cm/mo

7-12mo 7-12mo 0.5cm/mo 0.5cm/mo

1yr 1yr 46-46-47cm47cm

adult adult 55-55-58cm58cm

Tips for Calculating Tips for Calculating MedicationsMedications

lb. vs. kglb. vs. kg

11lb = 5 kg 22lb = 10kg 11lb = 5 kg 22lb = 10kg

33lb = 15kg 44lb = 20kg33lb = 15kg 44lb = 20kg

65lb? 73lb? 110lb?65lb? 73lb? 110lb?

1yr = 22lb at average, then 5-6lb/year1yr = 22lb at average, then 5-6lb/year

2 yrs? 3yrs? 5yrs? 2 yrs? 3yrs? 5yrs?

Tbs., tsp. vs. mLTbs., tsp. vs. mL

5ml = 1 tsp 3 tsps. = 1 tbs. 2 tbs. = 5ml = 1 tsp 3 tsps. = 1 tbs. 2 tbs. = 1oz1oz

Tips for Calculating Tips for Calculating MedicationsMedications

1 yr 22lb = 10kg1 yr 22lb = 10kg

Motrin Motrin 10mg/kg/dose 10mg/kg/dose 100mg/10kg/dose100mg/10kg/dose 50mg/1.25ml 100mg = 2.5ml50mg/1.25ml 100mg = 2.5ml 100mg/5ml (tsp) 100mg = 1 tsp100mg/5ml (tsp) 100mg = 1 tsp

Amoxicillin Amoxicillin 80mg/kg/day twice a day80mg/kg/day twice a day 800mg/10kg/day 800mg/10kg/day 400mg twice a day 400mg twice a day 400mg/5ml (tsp) 1 tsp twice a day400mg/5ml (tsp) 1 tsp twice a day

Physical Exam – BMIPhysical Exam – BMI

BMIBMI = Wt (lb) x700 / Ht (Inch) = Wt (lb) x700 / Ht (Inch)22 or or = Wt (kg) / Ht (m) = Wt (kg) / Ht (m) 22

ObesityObesity: BMI > 90th of the upper age range: BMI > 90th of the upper age range for children and teenagersfor children and teenagersRisk of OverweightRisk of Overweight: BMI 85th - 90th : BMI 85th - 90th

Estimated Normal BMIEstimated Normal BMI Girls < age +13Girls < age +13 Boys < age +12Boys < age +12

AssessmentAssessment

Symptom and disease orientated Symptom and disease orientated

Think about common diseasesThink about common diseases

Talk about Talk about

likely and unlikely, not yes and nolikely and unlikely, not yes and no

timely diagnosis timely diagnosis

basic concepts basic concepts

PlanPlan

Medical emergency handling Medical emergency handling

Symptom and disease orientated Symptom and disease orientated

treatment treatment

Good symptom relieving skills Good symptom relieving skills

Good following-up planGood following-up plan

Good patient/parent educationGood patient/parent education

Patient/Parent Patient/Parent EducationEducation

Symptom and disease orientatedSymptom and disease orientatedAnticipatory guidance Anticipatory guidance

Counseling Counseling HandoutsHandoutsWeb-sitesWeb-sites

BooksBooks

Medical DocumentationMedical Documentation

•If you didn’t write it down it If you didn’t write it down it means you didn’t do. means you didn’t do.

•If you did write down any If you did write down any abnormalities you have to abnormalities you have to interpret them.interpret them.

CliniciansClinicians what patients and parents look forwhat patients and parents look for

• Availability Availability • ConcernConcern• Knowledgeable Knowledgeable • Good clinical skillsGood clinical skills• Good communication skills Good communication skills • Good education skillsGood education skills• Good team work Good team work • Nice/clean officeNice/clean office• Reasonable billing Reasonable billing

Medical EducationMedical Educationat Ambulatory Pediatricsat Ambulatory Pediatrics

• MotivationMotivation

• ResponsibilityResponsibility

• Basic clinical skills Basic clinical skills

• Basic medical knowledge Basic medical knowledge

• Literature search skills Literature search skills

• Patient education skills Patient education skills

Thanks