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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While on my Pediatric Emergency rotation at BC Children's Hospital, an Emergency doc told me about the resources available to physicians and medical trainees put out by the Children's Hospital, namely clinical practice guidelines and the hospital formulary. While guidelines are debatable in terms of their foundation in evidence, it is always important to know what the standard of care is where you are working as a physician. Certain decision cannot be based in high quality evidence, simply because certain questions have not been asked and studied in rigorous scientific capacity. In these situations, local standards of care can provide guidance to select methods of providing treatment that are conscientious given local realities. Over residency, training in multiple environments and institutions, I have learned how valuable it is to know local resources, guidelines, pathways, and drug formularies, and once I start working in a given location long-term, I plan to become very well-versed in knowing what is available to me.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 1: Make the diagnosis of otitis media (OM) only after good visualization of the eardrum (i.e., wax must be removed), and when sufficient changes are present in the eardrum, such as bulging or distorted light reflex (i.e., not all red eardrums indicate OM). Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills Phase: Diagnosis, Physical Key Feature 2: Include pain referred from other sources in the differential diagnosis of an earache (ex: tooth abscess, trigeminal Neuralgia, TMJ dysfunction, pharyngitis, etc.). Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 3: Consider serious causes in the differential diagnosis of an earache (ex: tumours, temporal arteritis, mastoiditis). Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 4: In the treatment of otitis media, explore the possibility of not giving antibiotics, thereby limiting their use (ex: through proper patient selection and patient education because most otitis Media is of viral origin), and by ensuring good follow-up (ex: reassessment in 48 hours). Skill: Selectivity, Communication Phase: Treatment Key Feature 5: Make rational drug choices when selecting antibiotic therapy for the treatment of otitis media. (Use first-line agents unless given a specific indication not to.) Skill: Selectivity, Professionalism Phase: Treatment Key Feature 6: In patients with earache (especially those with otitis media), recommend appropriate pain control (oral analgesics). Skill: Clinical Reasoning Phase: Treatment Key Feature 7: In a child with a fever and a red eardrum, look for other possible causes of the fever (i.e., do not assume that the red ear is causing the fever). Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 8: Test children with recurrent ear infections for hearing loss. Skill: Clinical Reasoning Phase: Investigation According to the UpToDate article Evaluation of earache in children, "The diagnosis of acute otitis media (AOM) requires bulging of the tympanic membrane or other signs of acute inflammation and middle ear effusion. The importance of accurate diagnosis is crucial to avoidance of unnecessary treatment." Thus, if the view of the tympanic membrane is obstructed, one cannot make a diagnosis of acute otitis media. If there is cerumen impaction, this must first be disimpacted so that the tympanic membrane can be visualized. This can be done using cerumenolytics, +/- irrigation, +/- mechanical removal. And then, when the tympanic membrane is visualized, it is important to look for signs of inflammation suggestive of AOM. The most specific finding is a bulging membrane, which bulges from the increased quantity of inflammatory fluid in the middle ear space. Although a red tympanic membrane can be in keeping with an AOM, there other reasons that can cause the eardrum to become red (such as fever and crying, which are both common findings in children who are being brought in for assessment of possible ear infection but that may very well be occurring for reasons other than an ear infection). This means that a red eardrum in isolation is not a sufficient finding on otoscopy to make a diagnosis of AOM, and other sources of infection should be sought in a child with a fever. Although the most common reason for a child to present with ear pain is AOM, there is a big differential for ear pain that must be considered. My general DDx for ear pain is as follows:
If a patient does indeed have evidence of AOM then a decision needs to be made about whether or not to prescribe antibiotics. UpToDate recommends that children less than 2 years old with evidence of AOM on examination be given antibiotics, while being more conservative about antibiotic prescribing in children 2 years and up. They suggest that antibiotics in this latter age group should be prescribed based on the presence of any of the following features:
First-line treatment for AOM, according to Bugs & Drugs, is penicillin 40 mg/kg/d PO divided TID for 5-10 days in an otherwise healthy child, or 1 g PO TID x 5 days in an otherwise healthy adult (an uncommon disease process in adults). And whether or not antibiotics are prescribed, it is recommended that the ear pain be treated with oral ibuprofen or acetaminophen. If a child has recurrent AOM (defined as at least 3 episodes in 6 months or at least 4 episode in 12 months) with middle ear effusions, consider sending them to see an ENT Surgeon in consideration of tympanostomy tube insertion. The reason this would be done would be to prevent hearing loss and subsequent delay in language development in the child. If there are concerns about hearing loss that is ongoing after an AOM has been treated, consider that there may be persistent otitis media with effusion, and send the child for audiometry testing. If this is remarkable, an ENT referral would also be warranted. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 12: In children with traumatic injury, rule out abuse. (Carefully assess the reported mechanism of injury to ensure it corresponds with the actual injury.) Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, Hypothesis generation In my last post on trauma, I mentioned how it is important to consider abuse as being a reason patients may present with trauma. Depending on the trauma that has occurred, this may not be obvious, and when you see a loved one who seems legitimately worried about a patient at the bedside, it may seem downright counterintuitive. But victims of abuse are commonly brought in for medical care by the perpetrator, particularly when it comes to children and their primary caregivers. Assessing for abuse in children can be particularly tricky when it comes to physical trauma: children are clumsy and take chances exploring in sometimes dangerous ways. Getting injured is one of the ways we learn that things can harm us. UpToDate offers up some signs and symptoms that may help you pick up on a child with trauma secondary to abuse: Whenever you have more than a wisp of worry about abuse as a factor in a child's presentation for traumatic injuries, it warrants reporting the situation to the local child protection agency. Some physicians may hesitate to do this for fear of accusing caregivers who actually have not done any harm, which could have serious and unforgiving repercussions such as removing children from a home with caregivers who in fact provide good care. But reporting a situation that is questionable for child abuse does not mean you are charging the parents with abuse. It simply means the child protection agency will perform a thorough assessment to look for evidence that confirms or refutes child abuse. Given the prevalence of child abuse that is always too high (Statistics Canada), and the fact that, according to UpToDate, "Children returned to their families after an event of maltreatment have an 11 to nearly 50 percent chance of a second event," I think most people would agree that it is worth being overcautious at the risk of over-investigating cases and finding that many of them were in fact unintentional injuries.
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Behavioural Problems Key Feature 1: Because behavioural problems in children are often multifactorial, maintain a broad differential diagnosis and assess all factors when concern has been raised about a child’s behaviour:
Phase: Hypothesis generation, Diagnosis Key Feature 2: When obtaining a history about behavioural problems in a child:
Phase: History Key Feature 3: When treating behavioural problems in children for whom medication is indicated, do not limit treatment to medication; address other dimensions (ex: do not just use amphetamines to treat ADD, but add social skills teaching, time management, etc.). Skill: Clinical Reasoning Phase: Treatment Key Feature 4: In assessing behavioural problems in adolescents, use a systematic, structured approach to make an appropriate diagnosis:
Phase: Hypothesis generation, Diagnosis Learning (Patients) Key Feature 2: In children with school problems, take a thorough history to assist in making a specific diagnosis of the problem (ex: mental health problem, learning disability, hearing). Skill: Clinical Reasoning Phase: History, Hypothesis generation Key Feature 3: When caring for a child with a learning disability, regularly assess the impact of the learning disability on the child and the family. Skill: Patient Centered, Communication Phase: Hypothesis generation, Follow-up Key Feature 4: When caring for a child with a learning disability, ensure the patient and family have access to available community resources to assist them. Skill: Patient Centered, Clinical Reasoning Phase: Treatment, Referral Periodic Health Assessment/Screening Key Feature 1: Do a periodic health assessment in a proactive or opportunistic manner (i.e., address health maintenance even when patients present with unrelated concerns). Skill: Clinical Reasoning Phase: Treatment Today I saw three 4 year old kids who came into clinic with their parents for their routine vaccinations before entering kindergarten. These kids were impressive too - not a single one cried when I gave them their immunizations! Needless to say I was having a great day. All kids were healthy and without any history of significant medical concerns. During the last 4 year old visit, per my routine pediatric health check-up, I asked the patient's mom if she had any concerns. She described an odd tapping/pinching behaviour the child would do almost compulsively, which didn't sound so concerning but that was certainly out of the ordinary. I wasn't quite sure what to make of it, but I felt it was significant enough to warrant an assessment by a general pediatrician. At every pediatric check-up, I use either the Rourke Baby Record (ages 0-5 years old) or the Greig Health Record (ages 6-18 years old) to screen for any developmental or behavioural concerns, to promote wellness as opposed to just treating illness, and to obtain any screening investigations if indicated. These templates assess for medical conditions, psychosocial factors, and other developmental issues. I always make sure to include the child or adolescent's perspective as well, and in the latter case I always kick the parent/guardian out of the room to increase my ability to screen for certain issues such as domestic violence or sexually risky behaviours. When concerns are raised I also seek collateral information from other adults who look over the child or adolescent during the day, such as a main daycare or school instructor, as indicated. The reason for the comprehensive screening assessment is to be able to glance over the multitude of risk factors that may be contributing to behavioural concerns, which are more often than not a product of several interacting factors. That being said, it is important that treatments also focus on the multifactorial nature of behavioural concerns; it is rare if not impossible to find a pediatric behavioural concern that is best treated by medication exclusively. It is important to refer these children and adolescents for comprehensive assessments from specialised medical professionals and to build a team of interdisciplinary supports around them, as is feasible and available regionally, and as is tailored to the child's and family's values and interests. Although a small degree of difficult behaviour may be part of the natural development of children as they learn to explore boundaries and create an independent sense of identity, which is particularly true in adolescence, behavioural issues can also be very real manifestations of psychosocial precipitants or medical illness. Any behavioural concerns deserved to be explored and warrant some sort of intervention, whether it be parental reassurance or getting a whole team of community supports in place. As the primary care physician, it is important for me to recognize that issues that affect a child can really be affecting a whole family (not that this isn't true when adults have issues), and to check-in with how the rest of the family is impacted and how they are coping. It is also my job to ensure they have access to useful community resources that may help given their particular set of circumstances. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 3: Resuscitate newborns according to current guidelines. Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills Phase: Treatment Key Feature 4: Maintain neonatal resuscitation skills if appropriate for your practice. Skill: Professionalism Phase: Treatment I took the Neonatal Resuscitation Program about one year ago now, but I don't plan to renew this course as I do not see myself doing obstetrics once I have finished residency. However, on my pediatric nursery rotation, I have had the opportunity to put these skills to use. Currently, the most up-to-date neonatal resuscitation algorithm at this time is as follows:  Team Briefing: If the infant's expected gestational age is not less than or equal to 35 weeks, or if there is expected to be more than one infant, and if there are any risk factors for or signs of fetal distress (ex: meconium fluid), then a clinician skilled in neonatal resuscitation should be present in the delivery room specifically to provide care for the high-risk infant. Equipment checklist:  How to perform resuscitation maneuvers, if indicated: By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Immunization Key Feature 1: Do not delay immunizations unnecessarily (ex: vaccinate a child even if he or she has a runny nose). Skill: Clinical Reasoning Phase: Treatment Key Feature 2: With parents who are hesitant to vaccinate their children, explore the reasons, and counsel them about the risks of deciding against routine immunization of their children. Skill: Patient Centered, Communication Phase: Treatment, History Key Feature 3: Identify patients who will specifically benefit from immunization (ex: not just the elderly and children, but also the immunosuppressed, travellers, those with sickle cell anemia, and those at special risk for pneumonia and hepatitis A and B), and ensure it is offered. Skill: Clinical Reasoning Phase: Treatment, Hypothesis generation Key Feature 4: Clearly document immunizations given to your patients. Skill: Clinical Reasoning, Professionalism Phase: Treatment Key Feature 5: In patients presenting with a suspected infectious disease, assess immunization status, as the differential diagnosis and consequent treatment in unvaccinated patients is different. Skill: Clinical Reasoning Phase: History, Hypothesis generation Key Feature 6: In patients presenting with a suspected infectious disease, do not assume that a history of vaccination has provided protection against disease (ex: pertussis, rubella, diseases acquired while travelling). Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation Pneumonia Key Feature 9: Identify patients (ex: the elderly, nursing home residents, debilitated patients) who would benefit from immunization or other treatments (ex: flu vaccine, Pneumovax, ribavarine) to reduce the incidence of pneumonia. Skill: Clinical Reasoning, Selectivity Phase: Treatment Well-baby Care Key Feature 6: With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision:
Phase: Treatment, History Key Feature 7: When recent innovations (ex: new vaccines) and recommendations (ex: infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision. Skill: Professionalism, Patient Centered Phase: Treatment Today was my Resident As Teacher session, which meant I chose a topic that would be relevant to my colleagues and I to learn about, and then prepared and delivered a teaching session. I chose to focus on immunization, and I had my amateur improv friend collaborate with me to create an interactive learning session via improv games. The meat of the content revolved around the Immunization CFPC Priority Topic, and is outlined below. Key Feature 1 “There are a number of conditions that may be raised as a concern about receiving a vaccine, that in fact should not delay or preclude immunization. For example, routine administration of vaccines should not be postponed in persons with minor illnesses, such as an upper respiratory tract infection, otitis media, mild gastrointestinal illness, or concurrent antibiotic therapy. Repeated infectious illnesses are common in early childhood and will not interfere with the efficacy of vaccines. Generally, if a person is well enough to present for immunization in the outpatient setting, he/she is well enough to be immunized.” Resource: Canadian Immunization Guide Key Feature 2 5 steps to counsel the vaccine-hesitant parent (Resource: Canadian Paediatric Society Position Statement: Working with vaccine-hesitant parents):
Suggested reading: Preparing for Vaccine Questions Parents May Ask Key Feature 3 Vaccination schedules are province-specific. BC has published a set of routine immunization schedules for 3 populations (Resource: BC immunization schedules)
Key Feature 4 & 5 Be a responsible DAD
Key Feature 6 Know that vaccinations don’t guarantee 100% immunity in all people. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While currently on my Obstetrics & Gynecology rotation at St Paul's Hospital, I'm generally in the business of trying to promote healthy and safe pregnancies, among other issues related to supporting women's health. For women who do not want to carry forward a pregnancy, they would not be referred to our hospital service, although there are women who I have been consulted to assess in the emergency department who have had complications from abortions. In Vancouver, there are a handful of abortion clinics where women can go to receive comprehensive care if they wish to terminate a pregnancy. This has benefits because often not only do these clinics manage the medical side of things, but they also often link patients to resources for emotional and psychological support. As a primary care physician, it is important to be aware of the community resources available for a woman who wishes to terminate a pregnancy, and to provide the necessary medical care that is needed before referral and afterward in followup. Furthermore, many places in Canada will not have the option to refer patients to a local abortion clinic, simply because there aren't any near by, and as a result may need to manage most or all of the abortion process, or else the patient long distances away to get necessary medical care. Some physicians do not feel comfortable with this for moral reasons*, but it is legally required that these physicians refer the patient to another physician who will provide these services. We know that in places where safe abortions are not offered, women will proceed with unsafe abortions or try to do this themselves, leading to a much higher rate of morbidity and mortality. When a woman is determined to be pregnant, no matter her age, it is important to solicit whether or not the pregnancy was intentional and if not, if they want to continue to carry it forward or if they are considering terminating. It is important to address this early on, because if a woman wishes to terminate a pregnancy, this is much safer and arguably less traumatic when done early in pregnancy. That being said, it is important to provide appropriate and sufficient counselling so that a woman can make an informed decision that reflects her circumstances. If the patient chooses to terminate the pregnancy, then she has the option of doing so medically or surgically, depending on how far along she is. Medical abortion is typically provided until 49 days of gestation. That being said, it is critical to determine the gestational age as accurately as possible. There are pros and cons associated with each choice. Medical abortion is less invasive, and can be done at home, but can lead to discomfort over a number of days, and there is always the chance that it may not work and that surgical evacuation may be required. On the other hand, while surgical methods resolve the problem immediately and have less risk of failure, they are more invasive and have a higher risk of post-procedure infection. Performing an exam to assess pelvic size can help corroborate this, and unless ultrasound is inaccessible due to local resource limitations, accurate dating by ultrasound is the standard of care. If pregnancy is suspected based on the history and physical exam, confirming pregnancy is first done with a simple urine dip, and then the rest of the assessment would follow. Other investigations to obtain if proceeding with termination include determining the patient's Rh status and current hemoglobin level (if there is excess bleeding associated with the termination procedure, it is useful to have a baseline to compare to). STI screening should also be offered to all patients. In Vancouver, the preferred method for approaching a patient who wants an abortion is to refer to one of the comprehensive abortion clinics (see this website for a list of options), but if I find myself in a place where referral to such a clinic is not available, I can provide this service if indicated. The SOGC has an online course that is wonderful (I did this in medical school just for the learning) that equips health care providers with the knowledge and skills to provide medical abortions. And if I was in a place without Gynecological support, I could learn how to perform office-based aspiration/curettage procedures to meet this need. While medical management is generally effective, there are times when retained products of conception need to be mechanically evacuated. Heath care providers providing only medical abortion need to have a place they can send patients for surgical management if needed should the medical abortion be insufficient. Issues to address following the procedure itself include:
*To learn more about fetal and maternal legal rights as they pertain to abortion, along with major ethical and moral arguments that fuel the pro-life and pro-choice movements, check out this article that provides a good an concise overview of these issues. To learn more about ethical and legal "hot topics" in the world of reproductive and sexual health, check out the University of Toronto Faculty of Law webpage, Ethical and Legal Issues in Reproductive and Sexual Health. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 3a: In patients approaching the end of life: Identify the individual issues important to the patient, including physical issues (ex: dyspnea, pain, constipation, nausea), emotional issues, social issues (ex: guardianship, wills, finances), and spiritual issues. Skills: Patient Centered, Clinical Reasoning Phase: History As expressed in my previous post, palliative care aims to alleviate total suffering, including sources of physical pain or discomfort, along with emotional, social, and spiritual concerns. In patients who are approaching end of life, it is important to explicitly screen for concerns in these various domains, as some patients may not be as forthcoming about certain types of distress. Common physical issues that affect patients approaching the end of their life include pain, dyspnea, constipation, and nausea, and these are so common they are worth screening for specifically. Asking how a patient is feeling emotionally can open up a conversation about mood and anxious distress, and gathering a good social history can provide a framework for exploring social issues and revealing the extent to which advance care planning has been explored. Spiritual issues can often distress patients, consciously or unconsciously, as many patients are faced with difficult existential issues as they approach end of life. Taking a spiritual history is not something clinicians are trained to do very often, but it is essential in providing care that truly seeks to alleviate all sources of suffering. The approach I've adopted to taking a spiritual history comes from "Palliative Medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. It is summarised by the acronym "FICA" and is demonstrated in the following table as published in the book:  It's worth mentioning that the overall approach to pediatric palliative care is much the same, considering many of the same issues as for the adult patient. However, according to UpToDate, "Although the goals of palliative care in children are the same as those in adults, implementation of care is different because of the need for age-based care, differences in the underlying illnesses, the emotional and psychological issues in dealing with a poor outcome in a child, and the necessity of dealing with the child, parents, and in some families, siblings." The need for a strong team-based strategy with pediatric expertise cannot be stressed enough, and meetings that include the family are important to put together the most understanding and resources to maximize care. It's also important to consider how the patient's family and other loved ones may be impacted by anticipatory grief and eventually loss and bereavement of their loved one. Ensuring these support people are themselves supported promotes the capacity for the patient to be better cared for, and can help promote healthy adaption to life after loss. It helps to know the resources available within your community, as well as resources online or in print. These principles of integrating and caring for a family network are also esteemed for the care of adult palliative care patients.
Once you've asked and begun exploring any sources of discomfort, it's important to be an advocate for the patient in attempting to relieve their burden. Although many patients approaching end of life exude an astonishing degree of energy and capacity for autonomy despite the circumstances, many others may be too exhausted to do so, or not be aware of the possibility that some, if not most, of their physical, social, emotional, and spiritual suffering can be alleviated. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Dehydration Key Feature 1: When assessing the acutely ill patient, look for signs and symptoms of dehydration. (ex: look for dehydration in the patient with a debilitating pneumonia). Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 2: In the dehydrated patient, assess the degree of dehydration using reliable indicators (ex: vital signs) as some patients' hydration status may be more difficult to assess (ex: elderly, very young, pregnant). Skill: Clinical Reasoning Phase: Physical, Investigation Key Feature 3a: In a dehydrated patient: Determine the appropriate volume of fluid for replacement of deficiency and ongoing needs. Skill: Clinical Reasoning Phase: Treatment, Diagnosis Key Feature 3b: In a dehydrated patient: Use the appropriate route (oral if the patient is able; IV when necessary). Skill: Clinical Reasoning Phase: Treatment Key Feature 4: When treating severe dehydration, use objective measures (ex: lab values) to direct ongoing management. Skill: Clinical Reasoning Phase: Investigation, Treatment Key Feature 5: In a dehydrated patient: Treat the precipitating illness concurrently. Skill: Clinical Reasoning Phase: Treatment Key Feature 6: Treat the dehydrated pregnant patient aggressively, as there are additional risks of dehydration in pregnancy. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Treatment Diarrhea Key Feature 1a: In all patients with diarrhea: Determine hydration status. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 1b: In all patients with diarrhea: Treat dehydration appropriately. Skill: Clinical Reasoning Phase: Treatment Pneumonia Key Feature 2: In a patient with signs and symptoms of pneumonia, do not rule out the diagnosis on the basis of a normal chest X-ray film (ex: consider dehydration, neutropenia, human immunodeficiency virus [HIV] infection). Skill: Clinical Reasoning, Selectivity Phase: Diagnosis, Hypothesis generation Key Feature 3: In a patient with a diagnosis of pneumonia, assess the risks for unusual pathogens (ex: a history of tuberculosis, exposure to birds, travel, HIV infection, aspiration). Skill: Clinical Reasoning Phase: History, Hypothesis generation Today I encountered a 9 year female with congenital muscular dystrophy who was presenting with an acute cough, vomiting, and diarrhea. She looked unwell, and dehydrated, and on lung exam she had decreased breath sounds on one side of her lungs compared to the other. Chest xray revealed a middle lobe pneumonia. What are the signs and symptoms of dehydration? Late signs
Early signs
Evaluating someone's volume status (i.e., whether they are hypovolemic, euvolemic, or hypervolemic) is a clinical assessment; there are no tests that can specifically tell you whether or not someone is dehydrated or fluid-overloaded. It's all about considering various clinical indicators of volume status, and different patient factors can make certain indicators more or less useful. For example, in the very young patient, the degree to which their anterior fontanelle is filled, from bulging to very sunken, can be a very useful indicator of volume status, but this is not useful once the anterior fontanelle is closed, which is usually the case by the age of 2. Whereas in the elderly patient with wrinkled skin, using skin turgor to assess degree of dehydration is pretty well useless. And when it comes to the patient who is pregnant, a high index of suspicion is needed because there are many physiologic adaptations to pregnancy that may mask early signs of dehydration. Furthermore, the ramifications could be as significant as dehydration inducing uterine cramping and preterm labour, or could manifest in long-term complications related to impairments in fetal growth and development; a lower threshold to begin a rehydration regimen can have a significant benefit-to-risk ratio. Vital signs are a useful component of the evaluation of volume status as they are objective (including, in the pregnant patient, fetal heart rate +/- amniotic fluid volume assessment by ultrasound), but by themselves they may not be sufficient enough to determine volume status as abnormal vital signs can be a reflection of much more than volume status. For example, a dehydrated patient could be expected to be tachycardic, but tachycardia can also be caused by fever, or hyperthyroidism, or anxiety, or pain, etc. So the vital signs must be interpreted in the clinical context as well, much as the more subjective indicators of volume status need to be. When a patient is determined to be dehydrated, it's time to get them rehydrated while treating the precipitating cause, which for the above patient case meant to give antibiotic therapy for the pneumonia.* The approach to rehydration will depend on how dehydrated you think the patient is, and is generally clinically assessed as being mild, moderate, or severe. For any degree of degree of dehydration, from mild to severe, rehydration will consist of a replacement phase (to replace fluid debt; normal saline [NS] is always used) followed by maintenance (to replace ongoing losses; type of solution here will depend on context). The approach will also depend on patient factors, such as whether they are a pediatric or adult patient, whether they have comorbidities such as kidney disease or diabetes, whether there are any ongoing sources of fluid loss (ex: diarrhea, vomiting, sweating), and if they have an electrolyte disturbance. Note that most people walking around in the world are maintaining their fluids orally, and in general this is the preferred approach. In the severely dehydrated patient, however, oral replacement just won't suffice, and so intravenous fluid resuscitation is always indicated in this situation. In the moderately dehydrated patient, it is still very important to replace their fluid debt, but the situation is not as critical, at least not yet. If the patient is tolerating oral fluids and is well enough to drink lots of fluid, instead of automatically initiating intravenous fluid replacement, you may wish to consider a trial of oral rehydration first (if it would be feasible given the reason for the dehydration and the patient's ability to compensate). And then, if the patient is tolerating oral fluids, it's always best to try replacing fluid debt orally if the severity of the dehydration is nothing more than mild. It goes without saying (but I'll say it anyway for completion) that anyone who can tolerate oral fluids definitely does not need intravenous replacement (unless ongoing losses are so extreme that the patient just can't keep up). In this latter situation, the patient would be like everyone else who compensates for typical water loss in a day by taking in enough fluid in food and drinks to compensate for fluid lost in urine, stool, perspiration, and insensible losses (from the skin and respiratory tract). Sometimes this would be the only intervention that would be keeping a patient in hospital, and with patients/caregivers who you expect will be reliable to follow-up if things are not improving or worsening, it is a waste of health care resources and is usually less pleasant for the child who could otherwise be more comfortable in their own bed. Generally, patients who are assessed for urgent or emergent medical issues and who are deemed safe to follow-up as an outpatient may be discharged for outpatient management. This is preferred by most patients and healthcare providers, the latter of whom are also familiar with the real possible of secondary nosocomial illness secondary to hospital admission. For the patient with mild to moderate dehydration who is a candidate for oral rehydration therapy, is any fluid okay? Well any fluid is better than no fluid, but some fluids are better than others. In particular, the World Health Organization recommends Oral Rehydration Solution, which is a specific mixture of water, glucose, and salt. Because water follows sodium, if we have sodium in the solution, then as this is taken up by the gastrointestinal tract, more water will also get absorbed. There are also receptors in the gut that take up more sodium when glucose is present (sodium-glucose transport proteins), and so by adding in glucose as well, the uptake of water is even greater. To make your own Oral Rehydration Solution, combine 1L of water with a half of a teaspoon (2.5 mL) of salt and 2 tablespoons (30 mL) of sugar. Alternatively, there are products that can be purchased other-the-counter from pharmacies. For those in whom oral rehydration therapy will not suffice, IV fluids are indicated. Below are my approaches to rehydration in adult and pediatric patients, respectively, when IV fluids are required. Adult
Pediatric
All this talk of fluid replacement is getting me thirsty!  *Note that while this patient presented with x-ray evidence of pneumonia, many dehydrated patients may have a falsely negative chest x-ray early on in the disease process, which may also be the case for patients who are immunocompromised. If suspected clinically and the patient has risk factors for being unable to mount a swift early immune response, consider the need for empiric treatment for suspicion of pneumonia to prevent patient decompensation/deterioration. It's also important to consider risk factors a patient may have for acquisition of unusual pathogens, as may also occur in the patient who is immunocompromised or who has had unusual exposures to animals or other environments through travel. In the elderly or neurologically/cognitively compromised patients, consider their risk of chemical pneumonitis from aspiration. These risk factors matter because they influence choice of antibiotic.
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Disability Key Feature 1: Determine whether a specific decline in functioning (ex: social, physical, emotional) is a disability for that specific patient. Skill: Patient Centered, Clinical Reasoning Phase: Diagnosis Today I spent the afternoon in my home family clinic. Within 3 hours of seeing patients, I had developed management plans that included referrals to at least 3 different allied health care professionals, which is pretty standard in a comprehensive family practice. Community resources and professional supports can be extensive in urban centres such as Vancouver, so it really is beneficial to ask patients about what sorts of limitations their medical issues are creating for them - be they social, physical, or emotional - in order to access an extensive network of supports that can make a world of difference. I have always been asking my preceptor whom I am working with if they have a go-to professional or community resource in the indicated area, but it's about time I start building my own database of community-based resources and rehabilitation services to refer patients to. Thanks to a formal lecture given to my cohort of residents near the start of residency, I have some excellent resources to get me headed down a path of less resistance in order to suffice and surpass my patient's allied health and community resource needs. The online resources that I find particularly glorious for (resident) physicians working in British Columbia: No more excuses for me! Time to explore the options, find some health allies, and be resourceful in this province ripe with community support services.
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