History & Physical:

Peds H&P #1

 

Site Evaluation Presentation Summary:

For my mid-evaluation, my site evaluator went over our procedure logbooks and suggested I try to do more strep and flu swabs, but I unfortunately did not get to see those types of patients because I was in a different setting every week. We also discussed the important side effects of the medications we presented and other indications we might have not included.

For my final site visit, we received feedback on our H&Ps like trying to include lab results if they are a part of our plan and getting a more thorough family history. He also told us to avoid medical terminology when doing ROS. We discussed how COVID-19 has been affecting/limiting our experience with patient interaction since our previous visit. We went over our pharm cards and elaborated on important side effects and indications again.

My case presentation for the final site visit was a 14-year-old Russian male who came in for having recent intermittent diarrhea for 3 weeks that resolved a week before coming into the office, but he also complained of having acid reflux for 4 years. After presenting the HPI, ROS, and physical exam findings, my evaluator asked my 2 classmates for some differentials and explained why some might be higher on the list than others. Since the GI doctor I worked with had H. pylori as his first working differential, I presented a journal article that discussed probiotic use in the H. pylori regimen because I noticed all the GI doctors there were recommending its use when prescribing the quadruple therapy regimen.

 

Journal Article & Summary:

Helicobacter pylori treatment: antibiotics or probiotics

As I mentioned before, I presented a journal article that discussed probiotic use in the H. pylori regimen since I noticed all the GI doctors were recommending its use when prescribing the quadruple therapy regimen. The article is a review of H. pylori eradication treatment, focusing on emerging approaches to avoid the treatment failure, using new therapies with antimicrobials or with probiotics. Since there has been an increase of the antibiotic resistance, some studies have started to focus on probiotics as a therapeutic approach. The key regimen antibiotic with increased resistance has been clarithromycin and due to this, levofloxacin is used as a substitute in triple or sequential regimens. The eradication rate of therapies that contain levofloxacin could be more than 90% as opposed to the 70% that has been seen with clarithromycin. Eradication rates below 80% are not acceptable for H. pylori treatment. Probiotics has been used as monotherapy but this review established that it could not be recommended as a single agent for eradication but its usage as an adjunct will improve eradication rates and decrease treatment related side effects. Another review I briefly looked at mentioned a study that showed a difference between the control group (no probiotics) and the intervention group (adding probiotics) and the intervention group had higher clearance success rate.

 

Typhon:

Pediatrics Typhon Log

 

Self Reflection:

Before starting my pediatrics rotation I was a little intimated by the field because this age group is very different to handle and treat and because I have heard it can be hard to deal with worried/difficult parents. I was also worried I would not do well during the rotation because I felt unprepared with my limited pediatric knowledge. However, my experience went a lot different than expected.

NICU was my first week for this rotation and coming off of Psychiatry and into a critical setting was tough because I felt completely lost. I was very fortunate to have my NICU week land on a week with another PA student from NYIT doing her elective rotation in NICU. She happened to have worked in a NICU before she went to PA school, so she was very knowledgeable and helpful during this tough week. She taught me how to calculate I&Os for newborns, decision making tools for suspected sepsis, keys to physical exam, how to present a case during rounds, and answered any questions I had. Presenting a NICU patient was scary for me the first 2 days but after asking a lot of questions and doing it a couple of times, I started to get a little more comfortable with it towards the end of the week. Although NICU was only one week, I got to see/do some things I never thought I would. I had the opportunity to do an arterial stick on 2 newborns for blood cultures and although I was extremely nervous the first time because the newborn was tiny and crying, I was working with a very nice PA there who told me that this is normal and to keep trying until I get flash back of arterial blood. I also got to somewhat assist in the placement of an umbilical line on a newborn who had one umbilical vein and one umbilical artery, and the PA was teaching us the whole time on how this makes catheter placement for the artery more of a challenge. This week taught me a lot, especially how you can learn from your peers even though they are in the same boat as you and still learning.

Clinic week was probably my favorite week from the whole rotation because it taught me to overcome being scared of seeing patients on my own just because I think I’ll miss something important. Every time I presented a patient to the doctor I was working with, they would let me know what other questions I could have asked that were important to the patient’s presentation and by the end of this week, I had a better understanding of what questions were relevant to what symptoms. One thing I really liked about this week is that you weren’t assigned to specific providers and you were able to work with anyone you wanted to work with in the clinic and this gave me the opportunity to work with different types of providers. Some of them were better than others because some taught you things and talked about treatment/medications with you after and some did not. This week also gave me the chance to do well-child visits and see what kind of questions are asked and what exams are performed. I realized how important it is to ask kids about their diet, screen time, physical activity, and how everything is at home. One patient that stuck out to me during this week was a 15-year-old transgender F à M because it was the first time both the provider and I were treating a transgender patient. Seeing how supportive his family was towards him and how happy the patient was feeling because they felt more like themselves now was a memorable experience. Another patient that I will not forget from clinic week was a young male with suspected Noonan Syndrome. Before this patient, I had never heard of this syndrome and doing the physical exam was interesting because I got to see the genital abnormalities associated with this syndrome such as cryptorchidism and a “micro-penis” that was mistaken for a large clitoris when he was born.

Finally, my GI week was my second favorite week although it was also a frustrating one because my experience for the day depended on who I was working with. Some of the GI doctors were more willing to teach than others and some barely acknowledged my existence in the room with them. I had trouble dealing with those who thought my responsibility was to go grab their papers from the printer or dial the translator for them and not interact with the patient with us that much. There was only one GI doctor I really appreciated working with because she made me feel like part of the care team by having me see patients on my own before we see them together and discussed the patient in more depth with me after we were done with the appointment. What I enjoyed about GI week was the opportunity to be present in the procedure room for endoscopies and colonoscopies. Seeing the inside of the GI system and how they take biopsies was exciting and I also got to witness a bronchoscopy on a patient with tracheomalacia and obstructive sleep apnea. I enjoyed it the most when I worked with a doctor that taught me what we were looking at on the screen and how to know where your camera is along the GI tract.

Altogether, I learned a lot during this rotation, especially how to deal with the pediatric population and gaining more confidence with patient interviewing. I definitely liked the rotation more than I thought I would going into it.