Rotation 8 Peds Reflection

Types of patients you found challenging in this rotation and what you learned about dealing with them

Pediatric patients had always been a challenging population for me. They could be the worst historians that we would have to rely on the parents for history-taking. They could also be the least cooperative patients with the loudest crying and screaming. I had learned a lot about dealing with pediatric patients as well as calming them down during this rotation. At the beginning of the rotation, I found it very difficult to perform physical examination when the child was uncooperative, fussy, and irritated. Some younger patients would even start moving around and crying which would make it almost impossible to perform ear exam. I learned that patients could be held by their parents in a certain position so that they were not able to move. Then we would just be had to quickly perform the physical exam the best we could. In patients that refused physical exam, we could build rapport with the patients by listening to parent’s heart, then I would also let the patient listen to mine. It is important to spend time with the children and build trust so that we could perform physical exam smoothly.

 

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

Pediatric population could be a lot more challenging compared to the adult populations because they were not able to provide a full history and they could be very uncooperative. They could also be easily distracted when they were being exam. I have realized when interviewing the pediatric population, skills such as communicating on the child’s level is important. For examples, learning the child’s name in advance, physically getting down to the child’s level, or giving the child a helping role. I would also explain when I interact and touch them. Getting more involved with the patient will help gain their trust and make physical examination easier to complete.

 

What did you learn about yourself during this 5-week rotation?

During this 5-week rotation, I was stepping out of my comfort zone when I was interacting and communicating with pediatric patients as well as their parents. I always had difficulties getting involved and communicating with children. At first, I felt like I did not speak their language. During this rotation, I was getting exposed to pediatric patients in the ER, in the clinic, as well as in the NICU and mother baby unit. The age range can be very broad from a 1-day-old to an 18-year-old. Communication with patient of different age can be completely different. The more I was getting exposed to, the more comfortable I felt. It was a great experience learning how to care for pediatric patients and spending time educating parents and other caregivers how to care for their children.

 

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my next (also last) rotation at internal medication, I would like to observe procedures such as lumbar puncture. I did not get to see a lot of those in my previous rotations. Lumbar puncture is important to perform because it can help diagnosis serious infection such as meningitis and other disorders of the central nervous system. Besides lumbar puncture, I would also like to see and learn about paracentesis and thoracentesis. I would make sure that I tell the provider that I am working with on that day that I would like to see/perform more procedures. I would also study and read up on the patients that might require these procedures.

Rotation #8: Site Evaluation Summary

During the mid-site evaluation, I presented a case on community acquired pneumonia. Then I got tested on my own pharm cards as well as other student’s pharm cards. The site evaluator would also go over my procedure log books to make sure that I was doing procedures in my rotation. The feedback that he provided for my H&P was that I should be aware of that the patient was a child. Pediatric physical examination would look different compared to adult physical examination. Therefore, I should not include parts such as chest AP diameter 2:1. I should also elaborate on the social history, such as if the child went to day care or immunization up to date.

During the final-site evaluation, I presented a case on pityriasis rosea. Then I got tested on my own pharm cards as well as other student’s pharm cards. Then I presented an article on the efficacy on acyclovir on the treatment of pityriasis rosea. The feedback that I received was that I should had provided a more detail review of the disease during the presentation. The site evaluator also ensured that we are learning in our rotation site and that we feel safe in the site.

article

Effectiveness of acyclovir in the treatment of pityriasis rosea. A systematic review and meta-analysis.

Rodriguez-Zuniga M, Torres N, Garcia-Perdomo H.

An Bras Dermatol. 2018 Sep-Oct;93(5):686-695. doi: 10.1590/abd1806-4841.20187252. Review.

PMID: 30156618

Pityriaisis rosea manifests as an acute and self-limiting rash. An important goal of treatment is to control pruritus. Some of the recommendation include topical steroids, oral antihistamines, and even oral steroids. This objective of this article was to determine the efficacy of acyclovir in patients with typical pityriasis rosea. This is a systematic review and meta-analysis published in 2018 with 7 trials. There was a total of 324 participants with PR., with 159 were allocated to acyclovir, and 165 to control. Only 2 studies used low dose acyclovir (400mg 5 times daily), while the rest used high dose (800mg 5 times daily).

Results:

• Comparison of Acyclovir vs Placebo
• Acyclovir was superior to placebo after 1 week of treatment (RR 5.72, 95% CI, 2.36-13.88, I^2=0%). There was no difference at two weeks (RR 6.08, 95% CI 0.94-39.36, I^2=85%)
• Comparison of Acyclovir vs antibiotic
• Acyclovir was similar to erythromycin after 2 weeks, but superior after four weeks (RR 8.0 95% CI 1.13-56.33) and eight weeks (RR 2.16 95% CI 1.13-4.15) of treatment.
• Comparison of Acyclovir vs observation
• Acyclovir was superior to observation after one (RR 3.02 95% CI 1.13-8.08), two (RR 2.92 95% CI 1.50-5.66), and four weeks (RR 1.51 95% CI 1.10-2.08) of treatment.
• Comparison of combined therapy (Acyclovir + symptomatic treatment) vs. symptomatic treatment alone
• Combined treatment was not significant superior after two, four, and eight weeks of treatment

Conclusion: Acyclovir was superior to placebo and observation. However, combined therapy was not superior to symptomatic treatment for control of lesions. This result reflects that symptomatic treatment plays an important role for treatment. It is a reasonable option for PR, and the addition of acyclovir is justified for the control of severe symptoms.

 

Rotation 8

Identification:

Patient’s name: AJ

Age: 11

Gender: M

Race: Hispanic

Location: Queens Hospital Center, Pediatric ER

Date: 10/24/19

Informant: self and mother, both reliable

CC: “rash” x 1 week

HPI:

16 y.o male without PMHx, immunizations up-to-date presents to the ER with generalized body rash x 1 week. Patient described the rash as pruritic, started at the trunk and radiated to the upper and lower extremities, but not to the face, palms and soles, or genital area. The rash was mostly localized to the back of the trunk. Mother admitted to changing the brand of body lotion recently and did not give the patient any OTC medication for symptomatic relief. Denies previous experience of similar rash, recent travel, known food or drug allergies, sick contact, and sexual history/previous hx of STDs. No fever, recent URI symptoms, difficulty breathing, face or tongue swelling, or N/V.

PMH:

Denies PMHx

Past Surgical History:

Denies Surgical Hx

Medications:

Denies medication

Allergies:

No food or environmental allergies

NKDA

Family History:

Family history is not provided.

Social History:

Patient is a high school student. Denies use of illicit drug, alcohol, and tobacco. Denies being sexually active.

ROS:

General: Patient denies recent weight loss or weight gain, loss of appetite, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, or changes in hair condition. Positive: rashes, pruritus

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain. Denies hesitancy, dribbling or last prostate exam

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

 

Physical Examination:

General: 16 years old male is alert and cooperative. He is well dressed and doesn’t appear to be distressed. Neatly groomed, looks like his stated age. Well developed.

Vital Signs:

BP (seated): 115/75

HR: 70 BMP, regular

RR:  18 not labored

Temp: 99 F oral

O2 sat: 100% room air

Skin: 5 to 10mm in diameter lesions develop across the trunk and less on the extremities. Lesions occurs on the back tend to align in a typical Christmas tree pattern. The lesions are salmon color, ovoid, raised, with scale at the margin. (Herald Patch)

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white with cone of light.

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation.

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation bilaterally. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR.

Abdomen: Flat, symmetrical, no scars, striae, caput medusae or abnormal pulsations. Bowel sounds in all 4 quadrants. No bruits. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Male genitalia and hernia: did not perform

Anus, rectum, and prostate: did not perform

Peripheral vascular: The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological/Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

Did not perform

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations.

Sensory: did not performed

Reflexes: did not performed

Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Assessment:

16 y.o M presented with generalized body rash. Clinical presentation is most consistent with pityriasis rosea.

Differential Diagnosis:

• Pityriasis Rosea
• Allergic dermatitis/Eczema
• Tinea versicolor
• Viral exanthems
• HIV/Secondary syphilis

Plan:

• Oral Benadryl for itchiness
• Reassurance that the rash is not contagious and it is benign and self-limited
• F/U PCP
• Return to ED if symptoms worsen

 

Rotation8 Typhon Patient Encounter