1. Ambulatory Pediatric 101 Basic Clinical Skills Yingshan Shi, MD Lake Park Pediatrics July, 2007

2. Ambulatory Rotation The time to learn how to be a successful clinician 5Ws and How Why, Where, Who & Whom, What & How

3. Why AcademicClinic

4. Where Clinics Solo, Group Hospital Based Univ. Affiliated

5. Who and Whom Satisfy and Fit to Providers – team work Providers – team work Patients’ needs and Parents’ want Patients’ needs and Parents’ want

6. Patients Individuals Individuals Parents and Families Parents and Families Communities Communities Daycares and Schools Daycares and Schools

7. What Well Check-Up Sick Visits

8. How Concern Basic clinic skills - SOAP Know what is normal and red flag Education and counseling skills Right to the point

9. Basic Clinic Skills History Intake Use all your senses Vocal and non-vocal Evaluate patients and parents Symptoms addressed Detail and simplify

10. History Intake - Fever Fever 3 days and Max 102 Fever 3 days Day 1 101 at am 102 at pm Day 2 101 at am 101 at pm Day 3 100 at am

11. History Intake - Fever Fever 3 days and resolved for 1 day Day 1 101 at am 102 at pm Day 2 101 at am 101 at pm Day 3 100 at am 99 at pm Day 4 98 at am Fever 3 days and resolved for 1 day Max 102 on day1

12. History Intake - Fever How long How high by days and times Associated Symptoms Sick contacts, travel, pets, daycare and school attendants … PFSI

13. History Intake - Cough Cough 3 days Cough 3 days, dry and hash, Getting worse Worsen over night Waked up by coughing

14. History Intake - Cough How long How it sounds What time - day or night Getting better or worse Associated symptoms PFSI

15. History Intake - Vomiting Vomiting 1 day or vomiting 3 times today Vomiting 3 times today 1 st vomiting 12 hrs ago 2 nd vomiting 5 hrs ago Last vomiting 1 hrs ago after taking 4 oz milk

16. History Intake - Vomiting Vomiting 10 times today 1 st vomiting 1 hrs ago Last vomiting 5 minutes ago without drinking or eating solid food

17. History Intake for Sick Visits Symptoms Activities and Appetites Allergy and Medications Past, Family, and Social Birth, Feeding, and Immunization Sick Contacts Daycare and School Attendant PetsTravel

18. Physical Exam Well check-up: head to toes Well check-up: head to toes Sick visits: symptom orientated Sick visits: symptom orientated Medical problem: following-up Medical problem: following-up

19. Physical Exam – Vital Signs Temperature – Fever Axillary 99.5 °F (37.5°C) Axillary 99.5 °F (37.5°C) Oral 99.5 °F (37.5°C) Oral 99.5 °F (37.5°C) Rectal 100.4 °F (38°C) Rectal 100.4 °F (38°C)

20. Physical Exam – Vital Signs Nelson 16 th ed AgeBirth1-6y10y Heart Rate 100-18080-13070-110 RespiratoryRate30-6020-3015-20 BPSp/Dp6mo105/65105-110/67-70117/75

21. Physical Exam – Vital Signs Nelson 16 th ed WeightLength/HeightHC Pounds Pounds At Birth 7 5mo 14 11mo 21 1yr 22 >1y 5-6lb/yr Rule of 5 Rule of 5 Inches Inches At Birth 20 1yr 30 2-12y 2.5/yr Rule of 2.5 Rule of 2.5 At Birth 34-35cm 0-3mo 2.0cm/mo 4-6mo 1.0cm/mo 7-12mo 0.5cm/mo 1yr 46-47cm adult 55-58cm

22. Tips for Calculating Medications lb. vs. kg 11lb = 5 kg 22lb = 10kg 33lb = 15kg 44lb = 20kg 65lb? 73lb? 110lb? 1yr = 22lb at average, then 5-6lb/year 2 yrs? 3yrs? 5yrs? Tbs., tsp. vs. mL 5ml = 1 tsp 3 tsps. = 1 tbs. 2 tbs. = 1oz

23. Tips for Calculating Medications 1 yr 22lb = 10kg Motrin 10mg/kg/dose 100mg/10kg/dose 10mg/kg/dose 100mg/10kg/dose 50mg/1.25ml 100mg = 2.5ml 50mg/1.25ml 100mg = 2.5ml 100mg/5ml (tsp) 100mg = 1 tsp 100mg/5ml (tsp) 100mg = 1 tspAmoxicillin 80mg/kg/day twice a day 80mg/kg/day twice a day 800mg/10kg/day 400mg twice a day 800mg/10kg/day 400mg twice a day 400mg/5ml (tsp) 1 tsp twice a day 400mg/5ml (tsp) 1 tsp twice a day

24. Physical Exam – BMI BMI = Wt (lb) x700 / Ht (Inch) 2 or = Wt (kg) / Ht (m) 2 = Wt (kg) / Ht (m) 2 Obesity: BMI > 90th of the upper age range for children and teenagers for children and teenagers Risk of Overweight: BMI 85th - 90th Estimated Normal BMI Girls < age +13 Girls < age +13 Boys < age +12 Boys < age +12

25. Assessment Symptom and disease orientated Think about common diseases Talk about likely and unlikely, not yes and no likely and unlikely, not yes and no timely diagnosis timely diagnosis basic concepts basic concepts

26. Plan Medical emergency handling Symptom and disease orientated treatment treatment Good symptom relieving skills Good following-up plan Good patient/parent education

27. Patient/Parent Education Symptom and disease orientated Anticipatory guidance CounselingHandoutsWeb-sitesBooks

28. Medical Documentation If you didn’t write it down it means you didn’t do. If you didn’t write it down it means you didn’t do. If you did write down any abnormalities you have to interpret them. If you did write down any abnormalities you have to interpret them.

29. Clinicians what patients and parents look for Availability Availability Concern Concern Knowledgeable Knowledgeable Good clinical skills Good clinical skills Good communication skills Good communication skills Good education skills Good education skills Good team work Good team work Nice/clean office Nice/clean office Reasonable billing Reasonable billing

30. Medical Education at Ambulatory Pediatrics Motivation Motivation Responsibility Responsibility Basic clinical skills Basic clinical skills Basic medical knowledge Basic medical knowledge Literature search skills Literature search skills Patient education skills Patient education skills

31. Thanks