Cardiology

Pediatric Cardiology Expectations for PGY-2 and -3 residents
(Does not apply to PGY-1 residents on cardiology elective.)

Attendance:

Daily inpatient rounds every morning. Any days not on inpatient rounds must be accounted for with the service attending (vacation days, post-call days, continuity clinic days, and outpatient cardiology clinic days.) See below for inpatient service expectations.

Attendance at Cath Conference is expected every Wednesday at 4:30pm in the 2^nd floor interventional cardiology conference room if any inpatients are being discussed. This will likely be every week. You may be excused if no one you are following is being discussed. Clear with Cheri the morning of conference.

Outpatient clinics: When residents have continuity clinic in the morning they will be expected to go to Cardiology clinic (IHI/Schuman Pavilion) in the afternoon, unless otherwise instructed by the attending on service. For Med-Peds residents, when they will be in afternoon continuity clinic they should spend the morning in Cardiology clinic. If there is no clinic (rare), attend cath procedures or echo reading.

On other days, if the service attending agrees that the service is light, one resident may attend outpatient clinic while the other resident is rounding on inpatients, and either or both residents may attend afternoon outpatient clinics.

Inpatient Expectations:

Rounds: Contact Cheri Mathis (cmathis or pgr#5430) or the attending on service to decide on where and when to begin daily rounds, which patients to see, and which patients to write notes on.

Know a 1-liner for each patient on the list, whether or not you are personally seeing them: age, primary diagnosis, current physiology, and why they are in the hospital. Know what is keeping each patient in the hospital or from moving forward.

Presentations: Each attending prefers a different level of detail, discuss with Cheri or the attending for their preferences. Most importantly, your assessment, based on a review of the clinical data, should start with the 1-liner and include complications, significant additional diagnoses, and whether the patient is improving, worsening, or stable. Your plan should reflect the needs of the patient laid out in the assessment.

Consults: Discuss the reason for the consult with the primary team. Discuss the requested consult with the cardiology service attending prior to seeing the patient. See and assess the patient with a full history, physical, and review of available data. A first-time consult note (any time it is our first time seeing a patient in a hospitalization) includes ALL of the elements of an H&P, including the physician requesting the consult, a detailed HPI, review of systems, past history, social history, family history, vital signs, weight trends, detailed physical exam, respiratory and nutritional support, labs, imaging, ECGs, telemetry data, most recent echo, assessment and recommendations.

Notes: Particularly for the patients on 5800 after surgery, please use Dr Bock’s cardiology progress note template (PCNOTE) for the initial note. This is a useful progress note template but it does not include family history, social history, etc, and without editing is not sufficient for a complete consultation note. The note may be lifted from Dr Bock’s smart phrases as follows:

Click “Epic Menu” in upper left

Click “Tools”, “SmartTool Editors”, “SmartPhrase Manager”

Enter: “BOCK, MATTHEW J.” in the “User” field and click “Go”

Scroll down to “PCNOTE” and double-click to open

Click the “Owners & Users” tab

Click the “Add Myself” button on the bottom of the right column (“SmartPhrase Users”)

Subsequent assessments and notes: See the active patients in the morning and discuss their overnight events with the patient , bedside nurse, and telemetry tech. Review the available interval data and examine the patient. You must lay hands on the patients you are rounding on. A follow up inpatient progress note must be updated to reflect interval changes. This includes the correct date at the top of the note, changes in the physical exam, and an updated assessment and plan. Copy/pasters will be prosecuted.

If any of your patients have ECGs, review with the attending. Review echo result interpretation with the attending.

Afternoon rounds: Between 4 and 5pm check in with the attending with updates from studies completed during the day (particularly echocardiograms, X-rays, labs which you can request to review together), vital sign trends and significant events (extubation tolerance, procedures, etc.)

Academic Goals:
During the rotation, you are expected to give a 15 minute discussion reviewing a pediatric cardiology topic related to your future specialty. Ask for suggestions during the first week of the rotation if you are unsure of what topic to present. Report your chosen topic to Dr. Lo or your service attending for approval.

Review the topics below. It is your responsibility to review them on your own or with an attending if something is not covered by clinical experience.

1. Know normal age related heart rate and blood pressures
2. Know the differential diagnosis for chest pain in a pediatric patient, clinical features that would suggest cardiac pain, and plan the initial evaluation.
3. Know the differential diagnosis for syncope in a pediatric patient, and plan the appropriate initial evaluation.
4. Recognize signs and symptoms of heart failure (with and without cardiogenic shock) in different age groups.
5. Interpret pulse oximetry screening results, and identify cardiac causes of cyanosis, including periodic cyanosis in tetralogy of Fallot.
6. Understand the role of the ductus arteriosus in cyanotic congenital heart disease.
7. Recognize the major clinical findings associated with ventricular septal defects, atrial septal defects, patent ductus arteriosus, coarctation of the aorta, pulmonary stenosis, and bicuspid aortic valve.
8. Understand complications associated with congenital heart disease.
9. Know clinical findings associated with infective endocarditis, understand the natural history, plan a diagnostic evaluation for endocarditis, and plan appropriate prophylaxis for infective endocarditis.
10. Recognize signs and symptoms of myocarditis and pericarditis, and plan an appropriate evaluation.
11. Know the clinical signs and symptoms of arrhythmias.
12. Know the cardiac conditions associated with Turner Syndrome, Down Syndrome, Williams Syndrome, Alagille’s Syndrome, Tuberus Sclerosis, DiGeorge Syndrome, Trisomy 13 and Trisomy 18.
13. Understand indications for, and limitations of: ECG, Echocardiography, Chest Xray, Holter monitors, Treadmill stress tests, Cardiac MRI, Chest CT, and cardiac catheterization.

Clinical Goals:

1. Develop cardiovascular physical examination skills (including but not limited to auscultation).
2. Distinguish an innocent murmur from a pathologic murmur.
3. Interpret hemodynamics and oxygen delivery to direct evaluation and management decisions.
4. Observe the surgical planning for congenital heart disease, and gain exposure to postoperative care for these patients.
5. Evaluate an ECG for rhythm abnormality, QT abnormality, and signs of ischemia or hypertrophy.
6. Become comfortable with the initial management of common pediatric heart problems such as supraventricular tachycardia, congestive heart failure from left to right shunts, and hypoxemic spells in tetralogy of Fallot.

APPENDIX 1:

INPATIENT NOTES

People will judge your understanding of the patients and clinical situations by your notes, so make them good. Most importantly they must be accurate, with only current information in the assessment and recommendations. Anything short of this is unacceptable.
Tips:

•  Include a complete HPI or interval history. This includes symptoms with detail (timing, severity, etc) and/or interval events since the last note
•  Include cardiac medications with the current dose in mg/kg/day (or mcg if applicable), and continuous cardiac drips with doses and when the dosing was last changed.
•  Complete vital signs include whether there is a trend (example, heart rate overall decreasing over the last 24 hours)
• Note weight change, especially for patients receiving supplemental nutrition or those on diuretics
• Report nutritional intake in kcal/kg/day for all patients who are not PO ad lib
• Accurate physical exam, updated daily. Discuss findings with attending on bedside rounds if you are unsure how to describe the exam.
• Only include the most recent echo and ECG findings.
• Include information from telemetry review if it was performed.
• Only include pertinent labs – do not electronically insert the entirety of the lab data. We do not need to see the last 12 glucose readings.
• Assessments must include detailed diagnoses, complications, and assessment of whether the patient is improving, stable, or worsening for each diagnosis. Must be updated daily.
• Accurate plan, must be updated daily.

Suggested Reading

• Arrhythmias
• Congenital heart disease
• Hypertension
• Murmurs
• Pediatric chest pain