History and Physical Write Up
Journal Article
Increase in Pediatric Perforated Appendicitis
This journal article focused on the pediatric population with a greater focus on acute appendicitis presentations during a 2 month period in the beginning of the COVID era and compared to the appendicitis presentations with a control group in the previous years. This took place in NYC and focused on 3 large academic centers. Of those who presented to the ER with acute appendicitis, there was a higher perforation rate during the COVID era compared to the control group. The disruption of the healthcare system in relation to the COVID outbreak certainly has put the pediatric population at risk where families are more hesitant to bring their children for evaluation to the hospitals. This may have negatively impacted other aspects of pediatric diseases.
Site evaluation: My summary
My case presentation was about a 16-year-old male, with no significant PMH, who presented to the office with complaints of abdominal pain for the past 5 days. Pain was in the lower abdomen and was characterized as a stabbing pain. Pt rated the pain as a 10/10 now but initially was tolerable at a 3/10. Pt stated nothing makes the pain worse or better. Pt also complained of fever [101.3 oral], diarrhea, sore throat, painful urination, bloating, and feeling very weak. Imodium was taken to relieve the diarrhea with some relief. He is having difficulty now getting through the day and the pain is interfering with his daily function. He denied any vomiting, constipation, dysphagia, rectal bleeding, urgency, or hematuria.
This case was very interesting to me because it was not very clear cut as to how this patient should have presented for what the diagnosis ultimately was. After running some basic labs in the office, the patient was determined to have a WBC count of 18K along with tenderness in the McBurney point area as well as a positive psoas sign. Patient did have some slight rebound tenderness. The patient was rushed to the hospital for suspected appendicitis and it was then discovered that he had already had a perforated appendix and had developed an abscess to wall of the infection and contents that ruptured in his abdomen. Typically with a perforated appendix, the patient would experience a sigh of relief after having constant pain for a long time. This was not the case the patient also had other complaints that kind of had the PA and I kind of guessing as what it could possibly be. It was a very interesting case.
This was my 4th rotation and I believe presenting cases are becoming much easier now. Also having countless hours of patient interaction in the real world it makes me confident in what I am presenting as I have witnessed the patient myself where sometimes made up scenarios are very difficult to imagine in one’s head. I have gotten grate feedback from my presentation but one area that I received some comments on were the social history in the pediatric population. Within this age group, we want to know certain things that we would otherwise not ask an adult patient, for example, how they are doing in school, what are there grades like, is it remote learning or in person, any extra-curricular activities that do, etc. Just something to keep track of when writing up an HP for a pediatric patient.
Typhon postings
Self reflection
I am not the biggest fan of pediatrics but Professor Maida’s office in Staten Island, NY was a great experience overall. The staff was very friendly and the providers were there to answer any questions that you had about anything. It was my first outpatient rotation and I got to see what it was like dealing with the pediatric population and also the parents of the pediatric population. I remember professor Maida telling us during didactic year to prepare a speech to tell parents that they do not need antibiotics for every sore throat that presents in the office and that was definitely something I witnessed first hand.
Interpersonal challenges and how you addressed them
There is definitely a different feeling between working in a hospital setting vs an outpatient private office setting. Without the patients, the private office will not have any business and make no money. So in the back of your mind working at an outpatient setting, you kind of want to do your best at being professional and providing high quality healthcare because then the patients will likely return and perhaps recommend the practice to other friends/family to keep the business growing. Some parents and children were very welcoming to students and would allow me to examine a newborn child while other parents would not even let me look at their 15 year old son. So I had to shadow for those types of patients and learn the best way I can by asking questions/interviewing.
Types of patients you found challenging in this rotation and what you learned about dealing with them
Patients that I found a little challenging were the autistic patient population. These patients are not the best at expressing what bothers them and are very sensitive to touch. It was quite difficult for the PA themselves to get a good look at a child’s ear canal let alone me as the new student. They are particularly sensitive in the areas surrounding the ears so they would then start to kick/punch where sometimes we would need to hold them down for a quick second to get a good look to make sure there is no ear infection taking place. I find that sometimes children who are a little older and are diagnosed with autism, tend to do a little better when we carefully explain to them what is going to happen.
What was a memorable patient or experience that I’ll carry with me?
A memorable moment that I will carry with me was when a little 5 year old female was brought in to the room for a sick visit. She had not seen me before so she locked her eyes on me the entire time because she did not know what I was going to do. Being 6’2” and wearing a mask certainly did not help my case in winning over her trust, but I started to ask her some questions about school, what she liked to do for fun, if she enjoyed any Disney movies, and if she wanted a lollipop and stickers afterwards. It is sometimes difficult to to build rapport with an adult patient so when I started to build some rapport with the 5 year old girl, I felt very accomplished and slowly transitioned into the physical exam to see what was going on. I had to kind of play out of my comfort zone a little bit to because there are not many babies/young children in my family so I don’t have much experience interacting with young ones. It was a good experience that challenged me to make me better and an experience I wont forget because the little girl really liked me in the end and gave me a high five.
What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?
I want my preceptor/colleagues to notice that I can adapt to situations pretty well. Coming from the psych CPEP in Queens Hospital to a private pediatric office is a big jump, especially since offices are run in particular manner that I had to adapt to. We saw a plethora of patients each day and great outpatient settings have very little wait times so there was almost a sense of urgency when a new patient walked in where we tried to cater to their needs as best as we could and as fast as we could. So I had to start thinking of differentials right before we walked in the door based on the chief complaint to get a sense of what I was about to walk in to and what we were most likely going to recommend and do. After about a day, I got used to the flow of the office and almost knew before hand of what most likely was going to happen based on each chief complaint. Then I able to ask specific questions as to why certain choices were made while others were not. So I got to pick the brains of the providers a little bit to one day help me develop my own style no matter the population I will be taking care of.
