|
GUIDELINES FOR EVALUATION OF CHILDREN WITH URGENT CONDITIONS
VISITING THE PEDIATRIC PRIMARY CARE UNIT (PPCU) OR THE PEDIATRIC
EMERGENCY ROOM
The medical student's evaluation of a patient who comes to the PPCU or the Emergency
Department with an acute or urgent complaint may be tailored depending on the nature
of the complaint. One approach may be to use the S.O.A.P. format (see detailed example).
Here, following the "S" (subjective), one would include information about the acute visit.
For example, if the patient were presenting with a complaint of an earache, one would include
the onset of the otalgia, the presence or absence of fever, the height and duration of any
fever, the presence or absence of any upper respiratory infection, irritability or (less
frequently) symptoms of vertigo or hearingispeech impairment. At this time, one would also
ask questions about a past history for the complaint in question. In this example, one would
be very interested in the past history for previous episodes of acute otitis media (ADM) or
otitis media with effusion (OME). As well, one would ask about any pertinent family or
environmental history. A general review of systems may be undertaken at this time, for example,
documentation of the presence or absence of headache, conjunctivitis, sore throat, difficulty
breathing, cough, abdominal pain, vomiting or diarrhea, or symptoms of dysuria or frequency.
Following the "S" portion of the evaluation, one might then start to accumulate data under
the category of "0" ( Objective findings). This would essentially entail a complete physical
examination but specifically recording a detailed evaluation of the organ system in question
so that one would try to relate any physical findings to the information gathered under the
subjective part of the examination. Again, pertinent negatives are important.
Following and "(S)" and "(0)" portion comes the "A" part of the evaluation, which stands for
Assessment. The assessment for an acute visit may be brief but to the point; for example, in
this case the diagnoses may be 1) right acute otitis media and 2) and upper respiratory
infection. If there are other diagnoses considered in the differential, then these should be
included and, if appropriate, a brief comment as to why they may be less likely than the primary
diagnoses.
Finally comes the "(P)" portion of the evaluation which represents the plan. Here, again,
the plan should be concise, to the point and very clear so that anyone reviewing the chart
knows exactly what is being done for the patient and what exactly the follow-up plan would
consist of. It goes without saying that these plans should be communicated to the patient
and/or caretaker in terms that they can easily understand and follow. This is one of the
most important phases of the evaluation, especially if you are unable to provide follow-up care.
For example, in this case, the plan may be to: 1) begin the patient on Augmentin 250 mg per
cc suspension, 1 teaspoon TID for ten days; 2) for persistent effusion in one month's time;
3) at one month's time, consideration will be given to obtaining a tympanometry and hearing
assessment since the child has had a number of episodes of acute otitis media and also a
history of persistent otitis media with effusion. If the child has a PMD, then he/she should
be contacted initially to discuss the acute visit and later contacted for follow-up information.
This is one fairly direct approach to the evaluation of a child visiting the PPCU or emergency
department who has a relatively acute or urgent problem. This approach also may be used to deal
with a more complicated patient with multiple problems in the same setting.
The major problem is to be concise and yet complete. Take heart. If this seems difficult at
first' with time and experience you will gain the necessary skills!
|
|
Bio-Med 450: The Pediatric Clerkship |