History and Physicals:

Journal Article Summary:

For my site visit, I presented a journal article on the role of ultrasound in detection of radiolucent foreign bodies, specifically in the extremities. My patient presented with a laceration that xray revealed a radiopaque foreign body of 3mm. While his foreign body was detected on xray, other materials may not have been. In the case that a foreign body is highly likely and none is detected on xray exam, a patient would likely be exposed to a possible blind exploration. In patients with a positive history or clinically suspected foregin body and negative radiography, this study used ultrasound to investigate. Out of 120 patients, the ultrasound was positive for a foreign body finding in 114 patients and was able to guide surgical exploration. The majority of foreign bodies were removed from the feet and hands. This article determined that the accuracy was 94.16% and the sensitivity was 99.08% for the ultrasound guided findings. It determined that ultrasound was a highly sensitive and accurate tool for detecting and removing radiolucent foreign bodies that are missed by radiography.

Site Visit Summary:

For my site visit, one of the cases that I presented on was a 5yo male whose main complaint was penile pain. It was acute onset for 1 day and described as a tightness or pressure that increases in pain when urinating. The patient was still able to urinate normally in quantity and frequency. On a physical exam, the patient had a swollen shaft and head of the penis. The patient was uncircumcised with severe phimosis, and retraction of the foreskin caused extreme pain. There was also some scant yellow discharge with retraction. It was determined that the patient had phimosis with likely balanoposthitis. In the pediatric emergency department, the provider decided to transfer the patient to the pediatric urological service and Cohen Children’s Medical Center. It was an interesting case that we discussed as a group, because it seemed that with normal urination, this could be managed on an outpatient basis. My plan for the patient would have been Tylenol PRN for pain, Betamethasone cream 0.05% applied 2x daily for one week, and empirical treatment with  topical antibiotics like Polysporin or Mupicrocin. In addition, I would have recommended gentle retraction as tolerated with a twice daily bathing with saline solution to maintain good hygiene in the area. If the patient became unable to urinate due to pain or the volume of urine became scant, then I would move to a surgical solution like the provider recommended for the initial treatment. It was interesting to compare my thoughts for treatment to what the provider did, and be able to evaluate between the two options. We were able to discuss these options as a group after presenting, and determine what we thought would be the best outcome. On my site visits, I also became really familiar with the pharm cards that we all presented, which I found very helpful for my work on this rotation.

Typhon Case Log Totals:  

Reflection:

This rotation was unique as I was dealing with pediatric patients, which was extremely different from the past four rotations where I was working solely with adults. Additionally, pediatric opatients vary at different ages – I quickly learned that seeing a 4 month old is different than a 10 month old and a 3 year old and a 14 year old. It was challenging but fun to try and figure out the best way to interact with each age of patient I saw, in addition to their unique personalities. In the emergency department, I also had my eyes opened to the involvement of the parents in the children’s care, especially when they are concerned for their child. It was a good learning experience to deal with parents who were anxious or worried or frustrated. I remember one mother with a 3 month old that was having difficulty breathing and was determined to have RSV. She was extremely anxious and exhausted, and it was very stressful for her to be in the emergency department and watch her baby in pain. At one point all I did was hold her baby while she called her family, and it gave her some time to have a small break. It made me realize that the small things I can do to help patients and their families when they are at the hospital makes a big difference for them. 

I had a great time in the pediatric clinic, where I was able to work with both primary care pediatricians in addition to specialists. I particularly enjoyed working with the endocrinologist. It was a new experience to work with one diabetic patient to determine the best management for her, and to discuss and provide education regarding her care. I also enjoyed working with the pulmonologist, where we spent time working with a lot of asthma patients. I was excited to put my asthma knowledge to good use in order to determine the type of asthma and think about step up/step down management for these patients based on their current situation. I also learned a lot more related to patient education, and was able to see how important it is, especially with asthma patients, to show them how to use their inhalers for example. The doctor I was with that day took a lot of time intentionally showing them how to use their inhalers, and I think that was extremely helpful to the patients.

I also loved spending time with the new mothers and babies, in  addition to the NICU. It was an environment I haven’t spent much time in, and I found myself really drawn to it. It was actually an area I could see myself working in sometime in the future, because I enjoyed talking with the new mothers and evaluating their new babies. Additionally, I learned so much about management of new babies in the NICU. There is so much that goes into their care that I learned just from my week there. One thing I found very inter3esting was the use of caffeine for apnea/tachypnea in the NICU. At QHC, caffeine is used pretty liberally in patients that are apenic, tachypneic, or mechanically ventilated. It was great to read more about this therapy as I was unfamiliar with it before. I also really learned a lot from the doctors I worked with. 

Overall, I had a great time in pediatrics. It is definitely an area I could see myself working in someday. One doctor I worked with in the general pediatric clinic had me do physical exams on our patients, and one patient was particularly difficult. He was 4 years old and pretty shy, as well was very adamant about not being examined in any way – in fact he was on the verge of a tantrum. After talking to him for a little bit, he let me do the full exam – including checking his ears which I thought he would never agree to! Afterwards, the doctor told me I should consider pediatrics, and I can’t say I disagree. I had an amazing rotation and I learned a lot, and I’m excited to consider this field in the future.