Clerks Orientation 2022.pptx imp for ddx

Orientation

1. Clerks Orientation IMD Department of Pediatrics Davao Medical School Foundation Hospital ‹#›

2. Attendance Monday: Time IN: 7am-7pm Tues-Sunday : AM group: 7am -3pm; PM group: 3-11pm Divide the group equally into AM and PM group Then switch duties on Friday ‹#›

3. Attendance Use the bundy clock; Provide your own DTRs Ask any resident to countersign time in and out Log attendance in the logbook at the Pedia office (Room 336) Make sure to write the same time reflected in the DTR and in the logbook ‹#›

4. Attendance LATE: 1 to 30 minutes (from the required time-in) After 30 mins, considered ABSENT 3 lates= 1 absent ‹#›

5. Excused Absences Illnesses that require hospitalization Contagious diseases Death in the immediate family Court appearance Official Memo from Dean/Asst Dean Natural Calamities ‹#›

6. Absences -Medical certificate from the Dean’s office -Give within 2 working days after returning to duty -Excused: 1 is to 1 hours sanction -Unexcused: 1:3 hours sanction ‹#›

7. Prescribed Uniform School uniform with nameplate and black shoes Scrub Suit in the NICU and DR (change in the NICU-2nd floor) Level 3 PPE during rounds with the patient and consultant Additionally: Female clerks with long hair are required to tie it. Black and brown colored hair is allowed. Fingernails must be kept clean and short. Use of nail polish is not allowed. Use of dangling jewelries and other accessories are not allowed. ‹#›

8. In the NICU for baby catch Change scrub suit in the NICU (2nd floor) Change into blue slippers available in the NICU Wear face mask and headcap (provide your own) Do proper handwashing (ask assistance from the nurses) Fill up yellow form for pregnant mothers before delivery

9. Sample Yellow form Ask for pertinent infections for the past 2 weeks Ruptured bag of water >18 hours Gestation HPN, Gestational DM, Cardiac, thyroid Get the lab results of the mother from the mother’s chart and write in the yellow sheet

10. Sample Admitting Order Admit the patient in the NICU OBS Secure consent for care VS q 15 mins x 2 hrs, then q 30mins x 2 hrs, then q hourly x 2 hours then q 4 hours Routine Newborn care BCG 0.05ml ID right deltoid Hep B 0.5ml IM Vit K 1mg IM Erythromycin ophthalmic ointment both eyes For expanded newborn screening after 24 hours of life For critical congenital heart disease screening after 24 hrs of life For Red orange reflex Watch out for early jaundice, no bm and uo within 24 hrs, poor suck, hypothermia, cyanosis

11. Prescribed Uniform WARNING: Orientation First offense: 4 hours sanction Second offense: 8 hours sanction Third and succeeding: consider absent 1:3 hours sanction ‹#›

12. Out of Post Not in the assigned area during his/her duty schedule Not returned to his/her position after a 30mins break WARNING: Orientation First offense: 6 hours sanction Second offense: 12 hrs sanction third and succeeding: considered absent 1:3 hours sanction ‹#›

13. Required Materials for students Stethoscope Penlight Diagnostic set Calculator, measuring tape Sanitizer/alcohol Copy of drug doses and preparations (small notebook) Nelsons 21 st ed (ebook or hard copy) Fundamentals of Pediatrics by Navarro ‹#›

14. PLEASE BRING MATERIALS DURING ROUNDS

15. Data base One databases for the whole rotation for IMDs Type-written and submit a hard copy Use long bond paper IMDs- every Saturday, without FAIL Let any resident sign your database and indicate the time Use Nelsons for discussion ‹#›

16. Pointers in history taking If patient is less than 6 months, always start with perinatal history Patient was born to a G1P1, 29 yo mother, via NSVD….. If complaining of fever intermittent/remittent/persistent? undocumented/ documented? If documented, what is the highest recorded temp? What is the intervention? If given paracetamol, ask for the preparation, how many ml given, the frequency and compute the mkd What is the response to the intervention? With relief? No relief? Associated symptoms?

17. Pointers in history taking If cough productive/ non productive? What is the timing? Morning? Evening? Anytime? During cold? Dust exposure? Smokers? Pets? Intervention? Response? Family history of asthma? Previous history of the same symptoms? Associated symptoms?

18. Pointers in history taking If vomiting Characteristics? Bloody? Bilious? Post prandial? Post tussive? Component? Water? Milk? Previously ingested food? How many times? How much? 1 tsp? Tbsp? Cup? Intervention? Response? What was the last intake before vomiting? Associated symptoms? Abdominal pain? LBM? etc

19. Pointers in history taking If loose stools Characteristics? Bloody? Mucoid? Foul smelling? How many times? How much? 1 tsp? Tbsp? Cup? Intervention? Response? What was the last intake before the loose stools? Associated symptoms? Vomiting? Fever? etc

20. Pointers in history taking If any pain, headache, abdominal pain, etc O nset L ocation D uration C haracter (burning, crampy…? A ggravating R elieving T iming Intervention? Response? Add additional maneuvers if abd pain to rule out appendicitis Rovsings, psoas, obturator, etc

21. Data base and Case Pres Proper Order H and PE Salient features (pertinent positive, pertinent negatives in table form) Impression DDx (at least 3 and the admitting impression; put it in table form; give a little description of the disease) Admitting orders (include the rationale of the management in the ER) Lab results SOAP Discussion (correlate with the index patient in italicized form, use Nelsons or CPG) ‹#›

22. Example of correlation The following are the warning signs of dengue; persistent vomiting, lethargy, mucosal bleeding….. In our patient, she presented with mucosal bleeding.

23. Posts Do complete history and PE on RT-PCR negative patients ONLY Join a consultant during rounds with proper PPE Text the FB group when there is a consultant ‹#›

24. How to write Admitting orders? A Admit patient to (ward, private room, PICU) under the service of Dr. Carin D Diet: NPO, soft diet, Diet for age, no colored food, low fat diet M Monitor VS q hourly, 2, 4 hours I Ivf; Intake and output every 8 hours or q shift T Tests/Labs: CBC, CRP, Blood typing T Therapeutics/Medics: Paracetamol… Watch out for bleeding, hypotension, etc

25. Admission Conference With a consultant Every Monday, Wednesday and Friday Prepare powerpoint via Google slides Make a GC with the residents on duty Include chest xray films if done, pictures of skin lesions etc Include laboratory results Follow-up the patient before endorsement ‹#›

26. Daily Endorsement for NMDs With residents Every Monday, Wednesday and Friday (after adcon) Tues, Thurs, Sat, Sun or if without adcon, 7:45-8:00am in the Pedia office ‹#›

27. Progress Notes Provide your own logbook For NEW patients, include a complete History if you are not the one who fill out the pink form You can check the chart of the patients after getting the history, know the labs Do HEADDSS for patients more than 10yo Make progress notes before your resident around 7:00-8:00 am in the AM group, 5:00-6:00 pm in the PM group. And before going out ‹#›

28. Progress Notes Go rounds with your residents Progress notes your patients until discharge Progress notes on all patient assigned to you If discharged, pls inform me and share patients with your co-clerks ‹#›

29. Progress Notes Read about your case Correlate with your patient Admissions beyond 11pm should still be assigned to a clerk Pls check the census from the white board in the pedia office If there are watchers who will not allow you to interview them or do PE, inform Dr. Lim or Dr. Nono ‹#›

30. For Dr. Carin -Subjective and objective findings should be f rom the last time you saw the patient until your next rounds V ital signs should be reported in ranges (lowest to highest)

31. Problem Plan 1. Infection Paracetamol 250 mg/5ml, 5ml q 4 (10mkd) Ampicillin 250mg IVTT q 6 (100 mkD) D1+1 (include completed days) 2. . Dec plt CBC monitoring… 3. Still with signs of moderate dehydration IVF: D5NM at 100cc/hr (MR+60)

32. ALWAYS ENUMERATE PROBLEM LIST AND SPECIFIC PLANS!!!! DO NOT JUST COPY THE ORDERS. THINK AND READ!

33. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 1 only after 4 doses. So if only one sign, means D0+1 Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature 12nn 6pm 12mn

34. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 0+2 Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature 12nn With signature 6pm 12mn

35. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 0+3 Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature 12nn With signature 6pm With signature 12mn

36. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 1 Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature 12nn With signature 6pm With signature 12mn With signature

37. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 1+1 Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature With signature 12nn With signature 6pm With signature 12mn With signature

38. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 1+2, count only with signature. Ampicillin 100mg ivtt q 6 3/27 3/28 6am With signature With signature 12nn With signature —--------- 6pm With signature With signature 12mn With signature

39. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 0+2, you need 3 doses to complete day 1, so count only the signatures, it doesn’t matter what day it was given. Cefuroxime 100mg ivtt q8 3/27 3/28 6am —----------------------------- With signature 2pm —-------------------------- 10pm With signature

40. HOW TO COUNT COMPLETED ANTIBIOTIC? Day 1+1 Cefuroxime 100mg ivtt q8 3/27 3/28 6am —----------------------------- With signature 2pm —-------------------------- With signature 10pm With signature With signature

41. Read on your case Use Nelsons and Navarro Use CPGs We will ask theoretical questions too. MAKE SURE TO READ ALL THE MODE OF ACTIONS OF ALL THE DRUGS GIVEN TO YOUR PATIENTS

42. How to endorse patient? Endorsing patient, (Name, age, weight) Who came in due to (Chief complaint) With the Current diagnosis of: On his/her ___ Hospital Day, ___ Day of illness ___ hours/days afebrile Then start with the subjective complains…..

43. Case Presentation With Dr. Carin either via Zoom or Face-to-face One for NMDs and one for IMDs All clerks should know the history and PE Let the RIC/coordinator check your powerpoint the day before your report Include course in the ward in the reporting upto the last time you saw the patient before the presentation ‹#›

44. TIPS on making powerpoint Do not use FULL sentences Just put bullets 6 lines only per slide Use generic name for drugs (open close brand) Compute for mkd or mkD if there are medications Example: 4 days PTA Intermittent fever, Tmax 39C Associated with productive cough… Given Paracetamol (Tempra) 250mg/5ml, 5ml (13mkd) every 4 hours With temporary relief

45. TIPS on making powerpoint If there are lab results, pls put all findings in a tabular form Follow the proper sequence as mentioned in slide 21 F or the SOAP, you may tabulate, example S O A P (+) fever VS PE Dengue with WS Fever = Paracetamol Low plt= monitor cbc

46. Other reminders Do not get the charts from the station Do not take a picture from the chart Relay labs with interpretation and correlation with your patient; include previous result if available Example Hgb 132 (120) Hct 0.45 (0.39) Rbc 4.5 (4.6) Wbc 2.3 (2.2)

47. Just ask, don’t be shy! ☺ ‹#›

48. What do we expect from you? Elicit complete history and perform appropriate PE Interpret data to establish DDX and working impression and construct management plan Do relevant common pediatric procedure Conduct appropriate clinical investigation Conveys effective oral and written information about a medical encounter Carries out personal record keeping for professional development Carries out evidence-based medicine Carries out self-directed learning Know the basic anthropometric measures ‹#›

49. Basic Anthropometric Measures Growth Parameter Age Useful mnemonics Weight 0-6 months Age(months)x600+birth weight(g) if unknown use 3000g 7-12 months Age in months +9 /2 or Age(months)x500+birth weight(g) if unknown use 3000g 1-6 years Age(yrs) x 2 +8 (kg) 7-12 years (Age (yrs) x 7)-5 / 2 (kg) Navarro. Fundamentals of Pediatrics.p. Growth Parameter Age Useful mnemonics Length 0-3 months Birth length + 9cm 4-6 months Birth length + 9cm+8cm 7-9 months Birth length + 9cm+8cm+5cm 10-12 months Birth length + 9cm+8cm+5cm+3cm 2-12 years Age(yrs) x 6 + 77(cm) ‹#›

50. WHO charts https://www.who.int/childgrowth/standards/en/ Use WHO standard deviation charts for reporting Use it during endorsements and reporting ‹#›

51. Respiratory rate 3months-12months <50 1yr-5 yrs <40 > 5 yrs <30 ‹#›

52. Heart Rate Age Awake Asleep 0-3months 85-205 80-160 3-24 months 100-190 75-160 2-10 yrs old 60-140 60-90 > 10 yrs old 60-100 50-90 ‹#›

53. Blood pressure Lowest systolic BP Age x 2 + 70 Highest systolic BP Age x 2 + 90 ‹#›

54. Common Pediatric Drugs Drug Common Preparation Available forms Dose and Frequency Amoxicillin 125mg/5ml 250mg/5ml 50mg/ml (drops) 60ml 60ml 20ml 20-50mkD q 8-12 PO 80-90mkD for otitis media Amoxicillin-Clavulanate (Co-amoxiclav) 200mg /28.5mg/5ml 400mg /57mg/5ml 70ml 20-45mkD q8-12 PO Azithromycin 100mg/5ml 200mg/5ml 10mkD OD x 3 days 10mkD OD 1 st day, 5mkD OD x 4 days Cefaclor 125mg/5ml 250mg/5ml 20-40mkD q8-12 PO Cefixime 100mg/5ml 20mg/ml 8mkD q12-24 PO Neloson’s Pediatrics 20 th ed. ‹#›

55. TAKE NOTE In computing Coamoxiclav, only use the amoxicllin component, do not include the clavulanic acid e g . if Coamoxiclav 457/5, 400 is amoxicillin, 57 is clavulanic acid So only divide with 400mg

56. Common Oral Pediatric Drugs Drug Common Preparation Available forms Dose and Frequency Cefuroxime oral 125mg/5ml 20-30mkD q8 PO Clarithromycin 125mg/5ml 250mg/5ml 15 mkD q12 PO Clindamycin 75mg/5ml 10-40mkD q8-q12 Co-trimoxazole (TMP-SMZ) 40mg /200mg/5ml 80mg /400mg tab 6-20mkD TMP q12 Erythromycin 125mg/5ml 250mg/5ml 100/ml 60ml 60ml 10ml 30-50mkD q 6-8 Metronidazole 125mg/5ml 30mkD q6-8 Acyclovir 200mg/5ml 20mkd q6 x 5 days Sultamicillin 250mg/5ml 25-50MKD q12 Neloson’s Pediatrics 20 th ed. ‹#›

57. Common Oral Pediatric Drugs Drug Common Preparation Available forms Dose and Frequency Rifampicin (kidzkit) 200mg/5ml 120ml 10mkd Isoniazid 200mg/5ml 120ml 15mkd Pyrazinamide 250mg/5ml 120ml 25mkd Neloson’s Pediatrics 20 th ed. ‹#›

58. Computations ml = weight x mkD/mkd x per ml ___ mg (suspension) Example : 12kgs Paracetamol 10-15mkd ml = 12kg (15) x 5 250 = 3.6 ml or 3.5 ml Neloson’s Pediatrics 20 th ed. How to countercheck? 3.5ml = 12kg (mkd) x 5 250 mkd = 3.5ml (250) 12 x 5 =14.58 mkd ‹#›

59. Computations Example : 12kgs Amoxicllin 20-50mkD q8 ml = 12kg (30) x 5 250 = 7.2 ml for the whole day 3 (since q8) = 2.4 ml or 2.5ml every 8 hrs Neloson’s Pediatrics 20 th ed. How to check? 2.5ml x 3 = 7.5ml 7.5ml = 12kg (mkD) x 5 250 mkD = 7.5(250) 250x5 =31.25mkD ‹#›

60. Computations Example : 12kgs Cefuroxime 100mkD q8 mg = 12kg (100mkD) = 1200 3 (since q8) = 400 mg IVTT q8 Neloson’s Pediatrics 20 th ed. How to check? 400mg x 3 = 1200 mkD= 1200 12kgs =100mkD ‹#›

61. TAKE NOTE In counterchecking IV medications and tablet, directly divide with the weight No preparation needed Ex: paracetamol 500mg/tab, 50kgs patient 500mg/50kg= 10mkd

62. HOME MEDS IV antibiotics PO antibiotics Ampicillin Amoxicillin Co-amoxiclav Ampicillin-Sulbactam Sultamicillin Cefuroxime (2 nd ) Cefuroxime, Cefaclor (2 nd ) Ceftriaxone (3 rd ) Cefexime (3 rd ) Cefepime (4 th ) None Meropenem None The same generation of drugs ‹#›

63. Fluids and Electrolytes How to compute? ‹#›

64. Holiday Segar Alam niyo na yan! :) The maximum Total Fluid per day is 2,400 ml. If with dehydration 24 hr fluid= maintenance + deficit subtract IV fluid already administered Neloson’s Pediatrics 19 th ed. page 247 Dehydration <10 kgs >10kgs mild 50 30 moderate 100 60 severe 150 90 ‹#›

65. Fluid Computation Example: 12kgs came in with vomiting x 8 and LBM x7; seen tachycardic, sunken eyeballs, dry lips Compute for the Holiday Segar 2kgs X 50 = 100 + 1000 (from the 10kgs) 1,100 Deficit: 12kgs X 60=720 Neloson’s Pediatrics 20 th ed. ‹#›

66. Total fluid: 1100+720=1,820 In the ER, you gave 20cc/kg bolus (240) So, 1,820- 240=1,580 1,580 / 24 hrs= 65 cc/hr the maximum fluid rate is usually 100cc/hr Neloson’s Pediatrics 20 th ed. ‹#›

67. ‹#›

68. WHO Dehydration Management Plan A <2 yrs old 2-10 yrs old >10 years ols 50-100cc 100-200cc As much as he wants Plan B 75 cc/kg in 4 hrs Plan C <1 year old >1 year old 30cc/kg in 1 hr 70cc/kg in 5 hrs 30c/kg in 30 mins 70cc/kg in 2 ½ hrs ‹#›

69. ZINC < 6 months = 10mg > 6months = 20 mg Zinc drops: 1ml= 10mg Zinc syrup: 5ml= 20mg ‹#›

70. Probiotics Saccharomyces boulardii (Normagut) Lactobacillus rhamnosus (Gi pro tec 1+) Bacillus clausii (Erceflora) ‹#›

71. Electrolyte correction Na 128 K 2.8 SODIUM Deficit= (desired-actual)x weight x 0.6 Maintenance= weight x 2-3 Neloson’s Pediatrics 20 th ed. ‹#›

72. Fluid component Per 1 L Na K D5 LR 130 4 D5 0.3 51 - D5NM 40 13 D5IMB 25 20 ‹#›

73. Electrolyte correction POTASSIUM deficit= (desired-actual) x 0.4 maintenance=weight x 3 KIR= meqs x rate 1000ml =answer / weight =<0.2 Neloson’s Pediatrics 20 th ed. ‹#›

74. Immunization ‹#›

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78. Bronchial Asthma GINA 2018 ‹#›

79. Spirometry can be done by 4-5 years old if coached by and experienced technician ‹#›

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81. GINA 2018 ‹#›

82. Differential Diagnosis GINA 2018 ‹#›

83. Treatment trial : 2-3 months ‹#›

84.   ENDOTRACHEAL TUBE SIZE   Premature 2.5-3mm Term 3- 3.5 6mos 3.5-4 1 yo 4-4.5 2 yo 4.5-5 4 yo 5-5.5 6 yo 5.5 8 yo 6 10 yo 6.5 12yo 7 cuffed adolescent 7-8 cuffed  <1000g- 2.5 1000-2000 3 2000-3000 3.5 >3000 3.5-4 Term 3-3.5 1 yo 4 – 4.5 2yo 4.5-5 >2 yo= age(years)+4 4 ‹#›

85. MODIFIED COMA SCALE FOR INFANTS Eye opening score Spontaneous 4 To speech 3 To pain 2 None 1 Verbal Coos, babbles 5 Irritable cries 4 Cries to pain 3 Moans to pain 2 None 1 Motor Spont. Mov’t 6 Withdraws to touch 5 Withdraws to pain 4 Abn flexion 3 Abn extension 2 None 1 ‹#›

86. Breastfed Newborns input/output norms DOL HOL Milk vol /feeding (ml) Mother’s perspective # feeds #voids/ stool Weight loss 1 0-24 0-5 Drops 6-8 ≥1 BW 2 24-48 5-10 1 tsp ≥8 ≥2 ≤3% 3 48-72 10-20 1 tbsp ≥8 ≥3 ≤6% 4 72-96 20-30 1 oz ≥8 ≥4 ≤8% 5 >96 >30 > 1 oz ≥8 ≥4-12 Should gain ‹#›

87. Breast milk storage life ‹#›

88. HAVE FUN! :D ‹#›

89. ‹#›

90. Type “I will be a good doctor” in the group chat if you are done reading everything