Pediatrics, Week 1

Well, I have started pediatrics.  It is generally not the most interesting rotation, but there is a lot of stuff to memorize and it requires more participation.  Also, since it is a regular schedule, where I have to leave at 8:15 and end up back here around 6pm, I am finding my energy levels waning quite noticeably.  I've decided I'm just going to have to bring an energy drink every day to drink between 8 and 12, and that'll keep me going decently well for the whole day.  Luckily they don't cost much more than a cup of coffee, so it won't break my bank.  

As far as pediatrics goes, the most common visits involve a kid with a bad cold - usually with "sinusitis" or a possible ear infection associated with it.  If it's more than 2 weeks or the kid has strong symptoms, we prescribe antibiotics.  Personally, I think we are prescribing antibiotics too much and if it were me then I would not prescribe them, but right now I'm the student and I don't want to rock the boat.  We also see a bunch of kids for their ADHD, or monitoring their doses.  I still don't quite know what to make of it yet, as I've never attended a group session where the kids are seen interacting with each other and I don't know from experience what "normal" child behavior is.  Then there are the endless well-child checks, at 2 months, 4 or 5 or 6 months, 9 months, 12 months, etc.  We check their developmental milestones, answer parental questions, prepare the parent for the next stage of development and what to expect.  We haven't had any crying kids yet, so I'm kind of surprised - they are all really compliant with the exam, especially with the ear exam.  They've also let me examine them without much problem, they're all pretty nice.  I'm sure we'll have some combative screamers eventually, but so far so good.  

In other news, I finally got my isotretinoin medications today - better known as Accutane, though I have the generic version.  The process is extremely involved, especially if you are a female.  First you consult with a qualified physician who is familiar with isotretinoin, the indications, etc. and you discuss whether it is the right option - you are supposed to have exhausted every other treatment first.  Next, you get this packet for "females who have the potential to become pregnant."  You are required to read through everything, sign and initial tons of papers, and register and answer questions online swearing that you will use two forms of birth control (primary method such as hormones, an implantable device, or injections, and a secondary barrier method like a condom).  You must then wait for 30 days, and get a blood test within 7 days of your next appointment.  At that appointment the doctor makes sure you've done everything you're supposed to and that your blood tests check out, and they give you the prescription.  Once you have that, you have to take your special ID card, after having filled out the questionnaire online and registered, and go to your pharmacy to fill the prescription - if they do not have the medication on hand, then you have to wait until the next day when they will have it.  So...today was that day, and I now have it.  Side effects (aside from pregnancy) include skin sensitivity, depression, stomach upset, liver problems, skin dryness.  

I have seen some uncommon things though, which is cool - like Henoch-Schonlein Purpura and Roseola.  Also saw a case of Fetal Alcohol Syndrome, which is horribly tragic.  

Last Week of OB/GYN

Here I am, in my final week of OB/GYN.  Surprisingly little has happened between my last post and now.  There have been very few deliveries that I have been around to see.  I didn't do any 24 hour shifts last week because I was studying for my USMLE Step 1 exam (Feb 4).  I am also not doing any 24 hour shifts this week because I have my COMAT exam this Friday, which I take at the end of a block of rotations (e.g. OB/GYN, pediatrics).  As far as the USMLE goes, I think it went well, I am pretty confident I passed, and fairly confident I got around an average score.  It's hard for me to gauge because I took only one practice assessment and a lot of the questions that were on that test weren't very representative of the most commonly tested items.  Also, unlike practice questions, this test did not have very many of my weak spots on there; so, there were very few questions about CV/Respiratory physiology, elaborate equations, or complicated mechanisms about adrenergic receptors and drug combinations.  There were some endocrine questions which I may or may not have gotten right, and a few complicated ethical questions, but aside from those, I think I did decently well.  Only one or two questions were asking me about things I had no idea about.

Now onto this week - the most interesting thing that has happened was a woman in her mid-30s came in (she is in her late 2nd or early 3rd trimester) and she has profuse sweating, 102 degree fever, mild chest congestion, tachycardia, very fatigued.  She was kicked out of her house by the baby's father (likely because of her drug problems) and she was brought to the hospital by the homeless shelter people.  One of the more perplexing things about this case was that her white blood cell count was within normal range, and the ratios of cells was all practically normal - only up or down in a couple areas by 1 percentage point.  Also, her chest x-ray did not look very concerning - only some mild opacities along the central portion of her thorax and slightly on the left (mediastinum).  Her lung sounded pretty clear.  We also got a report from her past medical history that she has no asthma history, but she was diagnosed with hyperthyroidism back in the year 2000 and she said she hasn't taken any medications.  So of course the first thing I'm thinking is exacerbation of her thyroid disorder, possibly thyroid storm, because hyperthyroidism can cause all of her symptoms.  So my preceptor thought I might be onto something and ordered a stat TSH - it came back < 0.01 - in other words, something is suppressing her thyroid stimulating hormone production, this is most commonly caused by an excess amount of thyroid hormone causing feedback inhibition.  We ordered free T4 and free T3, as well as a thyroid hormone receptor antibody test to see if she has an autoimmune cause of hyperthyroidism (common in women 20-40) called Grave's disease.  My preceptor was very excited about me making a call she probably wouldn't have thought of - so hopefully that will reflect in my evaluation a bit - I haven't had any reviews yet that were particularly complimentary about my medical knowledge.  

At the moment I am keeping an eye on that patient from yesterday - her fever has resolved somewhat since starting the antibiotics for possible pneumonia, so maybe we just caught a really early pneumonia and the hyperthyroidism is just a longstanding comorbid condition.  Either way, hyperthyroidism is something really important to deal with in general, and in pregnancy especially.  I also have a presentation tomorrow about intrapartum anesthesia - emphasis on some of the lesser used modalities, such as nitrous oxide (commonly used outside the US), acupressure, and osteopathic medicine (mostly because my preceptor expressed interest).  I'll work on that when I get home probably, it's a little hard to focus here - I kinda need a break but I'm gonna stay at least a couple more hours.  My preceptor isn't here and we only have the one patient who probably isn't due for several weeks - and who knows if any other pregnant women will be coming in within the next few hours.  Even if they do, the odds that they will be imminently entering active labor are slim.

After my COMAT exam on Friday, I get to enjoy Valentine's Day weekend and then Monday I start Pediatrics after my Accutane appointment.  Wooh, fun times.