I was placed in Queens Hospital Center for my Pediatric rotation for 5 weeks. There I was in the pediatric emergency department for 3 weeks, then the clinic for 1 week and the NICU for 1 week. I learned how to manage patients from different backgrounds, and various complaints from emergent to well checks.

 

 1. History and Physical Write up 

Pediatric ED H&P 3

CC: “Fell and hit head” x 20 mins

HPI: A.S. is a 2 y.o. F with no past medical history, who was brought to the ED by her parents c.o. a fall and hitting her head 20 minutes ago. The patient’s father and mother are the source of history. Father states that the patient was playing and sitting on top of a medium sized luggage and while the father was in the room. The patient fell off the luggage and hit her head on the hard-wooden floor. Soon after she started to cry, and she had swelling on her forehead. The mother and father applied ice wrapped with paper towel on the swelling and came to the emergency room. Father states that the swelling has decreased since applying the ice. The parents didn’t give anything for the pain. A.S. is up to date on her immunizations and hasn’t had any recent illnesses.  Father admits to agitation, pain and swelling on the forehead and states no vomiting, loss of consciousness, disorientation, seizures, lethargy, fatigue, vision changes, fever, cough, and runny nose,

PMH: Denies

Immunizations: Up to date with immunizations. Received influenza vaccine on October 2019

Surgical Hx: None .

Allergies: NKDA

Meds: None

Social History: The patient lives with his mother and father, no siblings.

Family History:

1. Father: Alive and well at age 34yo
2. Mother: Alive and well at age 30yo

Review of Systems:

General: No fever, chills, loss in appetite.

Skin: Admits to swelling on forehead, no history of rashes, eczema, excessive bruising, or skin lesions.

Eyes: No eye discharge or pain, vision changes, excessive tearing, or itchiness.

Ears: No problems with hearing. No ear pain or drainage.

Head: Admits to recent head injury

Nose: No sinus infection or nasal discharge

Mouth and throat: No history of dental caries. No oral mucosa inflammation or lesions.

Neck: No pain, swelling

Respiratory: No cough or wheezing.

Cardiac: No history of murmur, syncope, cyanosis, or palpitations.

GI: No abdominal pain, diarrhea, vomiting, flatulence

GU: No trouble urinating

Differential diagnosis:

1. Hematoma secondary to minor head trauma
2. concussion
3. subdural hematoma
4. epidural hematoma

Vitals: Temp: 98.9 F oral. Pulse: 160 regular Resp: 22/minute O2 Sat: 98% on room air BP: 87/55 Weight: 28 lbs

Physical Exam:

General: Appears in distress and is crying.

Skin:  No visible lesions or rashes.

Head: 3 cm width by 2 cm thickness hematoma on the left frontal region with mild bruising and tenderness to palpation. No swelling or lesions elsewhere on the head

Eyes: No conjunctival injection or excessive tearing.

Ears: TMs is pearly grey with no budging. No discharge or drainage is noted in the external canals.

Nose: Nasal mucosa is moist. No purulent discharge or blood.

Mouth and throat: Oral mucosa is moist, without lesions. Gums appear healthy.

Neck: No swelling or tenderness

Lungs: CTABL. No wheezes, rhonchi, or crackles. No accessory muscle use.

CV: Tachycardia. RRR, no murmurs or gallops

Abd: Bowel sounds are present. Nontender, nondistended.
Neuro: CN II-XII intact

Motor: 5/5 upper and lower extremities

Sensory: intact to touch

DTRs: 2+ symmetric in upper and lower extremities.

GCS: 15

Labs: No labs/procedures.

Refined Differential:

1. Hematoma secondary to minor head trauma

Assessment: A.S. is a 2 y.o. F with no past medical history, who was brought to the ED by her parents c.o. a fall and hitting her head 20 minutes ago. On physical exam she has a 3×2 cm left sided frontal hematoma with mild bruising. Aside from tenderness she has no other symptoms. Finding are consistent with frontal scalp hematoma secondary to traumatic head injury.

Plan:

1. Hematoma secondary to minor head trauma
   1. R/o ciTBI: Follow PECARN rules and observe the patient for 4 hours to asses clinical status or any decline.
   2. Worsening symptoms or signs, order a non-contrast CT of the head
   3. Stop cool compress and observe how the patient reacts and the progression of the hematoma
   4. If the patient appears in no distress and is playful can discharge with follow up with PCP tomorrow.
   5. Parents are advised any worsening symptoms to return to ED

2. Article and Summary 

Link: Article

This is a systematic review and meta-analysis that included 16 studies and testing the efficacy of 14 clinical decision rules. They measured the specificity and sensitivity of each of the clinical decision rules. The looked at how well the clinical decision rules were accurate in identifying clinically important traumatic brain injuries and injuries that required neurosurgical intervention. They found the PECARN rule which is the most widely used in the US had a sensitivity of 98% and a specificity of 58% and for neurosurgical injury it had a high sensitivity of (98-100%). The CHALICE rule had the highest specificity of 86%. They also found that for identifying one clinically significant intracranial injury PECARN rule would scan 50 children and CHALICE would scan 18 and for identifying one neurosurgical injury PECARN would scan 200 children and CHALICE would scan 24. CHALICE is more cost-effective however the US uses PECARN.

3. Site evaluation presentation summary 

I had two site evaluations. I presented a case on balanoposthitis for my first site evaluation. My evaluator stated that it is common in that young uncircumcised boys. Since the hospital I was in did not have a pediatric inpatient or pediatric urology I presented what I would do if they did. My site evaluator appreciated this. I stated how I would ensure the patient can void before they were discharged, and how I would prescribe topical bacitracin to prevent infection. I learned that for my future H&Ps write about something a little more interesting. I chose a 2-year-old who had traumatic head injury. I choose it because their management was interesting and it utilized clinical decision tools. Presenting this and the article started an interesting conversation on management and CT use in children. I think I did well on my pharm cards on the first and second site evaluations.

4. Typhon 

Link: Typhon Totals

5. Self-Reflection

Exposure to new techniques or treatment strategies 

In the pediatric ED, I improved on my physical exam skills. The hospital’s ultrasound team does not read the appendix, therefore children that come in for abdominal pain and vomiting we need to rule-out appendicitis using physical exam skills. I utilized the special tests I learned in Physical diagnosis. Since there is no inpatient pediatrics in the hospital, the doctors observe the patients for a few hours before they discharge. I learned how to do a physical exam on many crying babies, and there are ways to do it so the child is more comfortable such as the parent holding the baby and facing away from the examiner. I also learned how to effectively do the Barlow and Ortolani maneuvers.

Interpersonal changes and how you addressed them 

I have had providers who were not receptive to having students work with them. In these situations, I find the providers just tolerate the student being there and are not interested in teaching or allowing the student to do physical exams. When I saw I was scheduled with a provider like this twice, the second time I tried to first let them know I was going to work with them but they still did not seem interested. It was my last day in the clinic and I wanted to learn, so I just told the person that schedules that I think I can learn more if I was with a different provider. She changed the doctor and I learned so much with the new provider.

How your perspective may have changed as a result of this rotation?

On the first day of my rotation, I saw a sexual assault case. The patient was young she was trying to hide her emotions behind a smile but her eyes were welling up with tears as we were interviewing her. The patient was informed about how long the process would be. When the parents were told she would need to go on 1 month of HIV prophylaxis they were broken. I always knew that sexual assault cases were serious and sensitive, but that day I learned how confused young children are when they come to report this. They are scared and have to repeat the story often. As healthcare providers, we should remember to be sensitive and keep in mind that young children process emotions differently than adults.

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

For future rotations, I would like to be more independent if my site lets me. For example, instead of shadowing providers, I would like to do my own physical exam, assessment, and plan and then present it to the provider and discuss any changes or improvements I should make. I feel like I need to improve on my plan for patients, I am either doing too much too little. I plan on working on this by building a strong rapport with my preceptor in the fist week, so for the rest of the rotation, they can trust me to see patients on my own and present them. I am hoping my next rotation I would be able to improve on this.