Nephrology (Peds 426)

Welcome to the Pediatric Nephrology Rotation!

1. We look forward to helping you both enjoy and maximally benefit from your experiences over the next 2-4 weeks. We hope you will take advantage of your elective time to broaden your exposure to issues related to kidney health and disease in children, and to solidify your knowledge of renal physiology.

2. The attending will change every week on Fridays.. Please check with your attending on call for any changes in the schedule. Page or email the pediatric nephrology attending on call to find out when and where rounds will be or discuss day prior. We generally meet up each morning in the PICU (2nd floor of Children’s Hospital) or the 6th floor of the Children’s Hospital.

3. You will receive impromptu teaching on rounds, relevant chalk-talks throughout the day as time permits, and will have dedicated renal teaching time several times per week (see below).

4. You should expect to give and receive performance feedback from and to your fellow and/or attending on Friday afternoons each week. Please ask for this if attending forgets!

TIME	MON	TUE	WED	THUR	FRI
8:00	Morning Report	Morning Report	Morning Report	Pediatric Grand Rounds	Morning Report
8:30/9:00	Peds Neph Clinic – 100  Eastowne Dr	Round on inpatients	Round on inpatients	Round on inpatients	Round on inpatients
12:30		Gen Peds Noon Conference	Noon: ped neph clinic conf on zoom	Gen Peds Noon Conference	Gen Peds Noon Conference
Afternoon	Peds Neph Clinic	New consults, note writing, teaching	New consults, note writing, teaching		3 pm: inpatient review on zoom

*Nephrology Offices & Conferences are located on 7th floor Burnett Womack
Attendings: Keisha Gibson, Dorey Glenn, Keia Sanderson, Katie Westreich, Jess Stahl, Liz Kotzen
Fellows: Duy Vu, Anisha Gerber, Ashley Carver
Staff: Lynn McCoy, RN

Expectations: General

• Be kind, respectful, and reliable
• General hours are 8:30 am – 5 pm M-F (morning report attendance is up to you or per residency guidelines)
• Let us know ahead of time if you’ll be absent for interviews, doctor’s appts, or other responsibilities

Expectations: Outpatient clinic

• Outpatient clinic is every Monday from 8:30 am – 5 pm on the 3rd floor of the Eastowne Building at 100 Eastowne Drive, Chapel Hill. Please park on the 4th floor or higher, then proceed to 3rd floor and ask the front desk for directions to the Pediatric Nephrology workspace (pod F) on Monday morning.
• Participation in clinic visits will depend on clinic schedule and available preceptors. Attendings can guide you towards good patients to see. Ideally, we will guide you towards new patients so you can think through differential diagnosis and work up. We are more than happy to sit down with you for a few minutes before you go see a patient to help orient you. Start visit with the patient, get history, perform pertinent exam unless it’s a sensitive exam and you’d like to wait to perform it with your attending. Your part of the exam should take less than 15 minutes in most cases. Present the patient to your attending, as well as your ideas about differential diagnosis, work up, and plan (keeping in mind we understand you are working on the fly and haven’t had time to read or sit and think).
• Write note for the patient – for a new consult, please use Katherine Westreich’s template smartphrase KWOUTPTCONSULT (get access to KWEXAMCHILD as well), OR ask the attending you are working with if they have a new consult template they prefer you to use. If the patient has been seen by our group before in the hospital, then use the return visit template KWOUTPTRETURN. If it’s a transplant patient’s first visit in clinic then use KWTRANSPLANTFOLLOWUP.
• For return patients who’ve been seen in our clinic before, please pull forward the last note, clean it up so its brief but as complete as necessary (for instance, summarize the presentation in one sentence rather than every detail of their initial presentation beyond the initial consult note) and update everything in it to be relevant for today’s visit (including changing it to a follow up note, if their last visit was their initial consult). Please finish your notes by the end of the day, so we can sign them that night.
• Outpatient notes from a consult service have a special purpose that is quite different from that of a patient’s primary care provider.
  • The goals of a consult note are many:
    • gather and organize the relevant history
    • explain the differential diagnosis and work up that follows based on it
    • find a diagnosis (if possible)
    • explain that diagnosis to the referring physician
    • recommend or start a treatment and explain that treatment to the referring physician.

Additionally, there should be anticipatory guidance for the referring physician (side effects or prescribed therapies to watch for, reasons to refer back to us sooner than scheduled follow up).

Two common pitfall to avoid:

• teach, but don’t condescend to your referring physician
• obtaining labs and acting on the results are part of your plan but drawing labs is not the whole plan.

Language to avoid: Patient is here with hematuria, differential diagnosis includes x, y, and z. Plan: RFP, urine protein to creatinine ratio, ANCA , anti-dsDNA”.

Suggested language: Assessment: patient here with hematuria, differential diagnosis includes x, y, and z. Based on presentation, my money is on x or y with the following rationale. Labs are pending. Will addend this note when with results and my interpretation and will outline determine a plan based on those results.” You will receive feedback on your progress writing consult notes throughout the rotation. Please ask us for feedback if you don’t get it within a couple of days!

Expectations: Inpatient service

• Rounds are typically at 8:30 or 9. Discuss time and location with your fellow or attending the day before, or page them after morning report. Pre-rounding is not expected but I’ll be honest – it’s both impressive AND helpful.
• You will be given the opportunity to see new consults and follow existing consults, following a total of 2-5 patients depending on your level of training and number of patients.
  • For new consults: discuss first with fellow/attending on call, then go see patient, gather history and physical, come up with differential diagnosis, assessment, and recommendations. Present to attending/fellow. Read relevant medical literature about your patient’s condition, work up and treatment before presenting your plan (as time allows).
  • For existing consults: discuss with fellow/attending whether a note is needed that day.  Discuss nephrology’s recommendations and plan with the primary team. Serve as primary point of contact for your patients and the primary team, and a conduit for communication in both directions.
• Inpatient consult notes: should include what to do, but also your rationale. Your thought process on the patient should be transparent. Include a detailed explanation of the differential diagnosis and your thoughts about what is going on for the patient, as well as recommended work up and management, with clear anticipatory guidance for what to do overnight or if things change (ie sodium goes up too fast, SBP exceeds 150, etc). Use Katherine Westreich’s KWINPTCONSULT for new consults or ask your attending which note template they prefer (probably their own!).

Expectations: presentation

• On the last week of your rotation at the Friday inpatient review, we would like you to present a 5-minute talk on your chosen renal topic. Powerpoints not necessary, chalk talks or a one-page handout are great.
• Topics: fellows and attendings, provided time, will give chalk talks on the following topics. Please make sure you have your high priority topics covered during your rotation! Keep track of what you’ve had and what you still need.

Outpatient	Inpatient ICU	Inpatient floor
PCP work up prior to referral –hematuria –proteinuria –HTN	Dialysis –CRRT –iHD –PD	Edema management –with nephrotic syndrome –outside of nephrotic syndrome
CKD	Hypertension
Hypertension	New transplant
Transplant	AKI
Nephrolithiasis	Sodium and potassium dyscrasias
Nephrotic Syndrome	Metabolic acidosis/RTA
Vasculitis	Assessment of fluid status: volume depletion, volume overload
	Fluid overload	New GN cases
		ESRD
		Peritonitis