Pediatrics

I'm four weeks into my six week peds rotation. At my site (Hope Children's Hospital), I spend three weeks on a general floor, one week in the nursery, one week in outpatient clinic, and one week in a subspecialty (just finished up my peds GI week).

Taking a further step back, this half of my M3 year is more medically oriented (vs. surgical - e.g. ob/gyn, surgery). As such, I have had dust off my thinking cap and throw it on in the morning. And there was quite a bit of dust on my hat.

At this stage in our careers, I'm realizing it's not all about nailing the correct diagnosis. Yes, it's nice when your residents and attendings agree with your assessment But it's all about thinking about what something could be and what else it could be.

Take appendicitis for example. Classically, it will present in 10-15 year olds beginning with diffuse abdominal pain and cramping that localizes a few hours later to the right lower quadrant, 2/3 the distance from the navel to a hip landmark. Pain should precede any vomiting or anorexia (vice versa in gastroenteritis). On exam, the patient'll probably be febrile, hopefully without any peritoneal signs, and hopefully positive one of a few classic signs: psoas, obturator, Rovsing. It's said that 80%+ of diagnosis is based on history and physical and they guide appropriate workup. A story convincing for an appy will buy you a CBC to confirm infection and probably imaging to confirm that you've actually got an appy.

The story I just gave is pretty straightforward for an appendicitis. In thinking of right lower quadrant pain, one's also gotta consider adnexal cysts/torsion, ectopic pregnancy, PID, mittelschmerz, mesenteric lymphadenitis, Crohn's, volvulus, intussusception, pyelonephritis, urolithiasis, Yersinia enterocolitica. In entertaining thoughts of appendicitis-mimics, the vice versa also has to be considered - appendicitis mimicking other conditions. That is, appendicitis presenting in an atypical fashion.

Long story short, it's interesting having to actually think through a patient's story. And I'm pretty sure I like the process. Even though I'm realizing how much I don't know at this point. At the same time, I still have an itch to do procedures. Sooo, I still haven't made any progress in the surgical vs. medical debate.

That said, I'm actually enjoying my peds rotation a lot more than I thought I would. The floor patients are pretty interesting - if a kiddo's in the hospital, there's got more going on than the stereotypical sore throat or ear infection. Patients I've had include: congenital heart defects (mostly tetralogy of Fallot), foreign bodies, ovarian cysts, nephrolithiasis, pill ingestions, hydrocephalus, diabetic ketoacidosis, Crohn's, supraventricular tachycardia, common variable immunodeficiency, and seizures. More typical peds admissions include RSV bronchiolitis (shittons) and appendicitis.

On a sadder note, some kids ended up having with serious shit. I.e. hepatocellular carcinoma, leukemia (ALL), and osteosarcoma. The osteosarcoma was particularly sad - a 17 y/o girl whose presentation was a lumbar vertebral fracture leading to paraplegia. It was on her workup that a femoral osteosarcoma was found with metastases to her abdomen and spine.

Those sad stories aside, probably the only interesting case to nonmedical folk would be an incidental finding of pinworm in a girl getting scoped for Crohn's. Note: the upcoming in parentheses might be a bit disgusting.

(Classically, its presenting symptom is perianal itching. If having worms in your colon isn't offensive enough, the reason for the itching is because they come out of your GI tract at night and lay eggs perianally - it's these guys that cause the itching. The traditional diagnostic test is the scotch tape test. Double side some tape around that area before bed, let them do their thing, have a look at the tape in the morning.)

Now that I've gotten sad and disgusting stories aside, there's not much to write home about. I'm shocked at how much I'm enjoying the rotation. I can appreciate the diversity in pathology, patient age, and the fact that kids' problems aren't self induced (alcoholic cirrhosis, noncompliance, etc). In all honesty, it's playing with the little ones that's the best part of my day. Especially the 3-15 month olds in clinic - good age group and if they're in clinic they're reasonably healthy and amenable to playing. This week I'm in the nursery and the NICU. Not gonna lie, the kiddos are pretty cute.