Rotation Reflection

My third rotation was Pediatrics at Dr. Hurwitz’s office in Queens. Among the many things I enjoyed about this rotation, perhaps the most important, Dr. Hurwitz was a fantastic preceptor. From the first day I was thrown in to examine patients, report my findings and offer a treatment plan or next step in management. I followed him to examine every patient after examining them myself and he’d always ask me what he’s looking for if the clinical presentation pointed towards a specific diagnosis. For example, one patient presented with a rash on his hands, back of his neck and lesions in his mouth. Dr. Hurwitz asked the patient to remove his shoes and socks to check his feet and asked me what he’s looking for in which I replied, Coxsackie or hand-foot-mouth disease. His questioning and expectations of both my physical exam and evaluation pushed me and kept me on my toes.

I am thankful that the time I spent at the office was super busy and each day was packed with both sick and well visits. In the past few weeks there has been a rise in cases of bronchiolitis, most commonly caused by RSV. I was able to see the whole spectrum, which is very wide, for RSV with some children presenting with a low-grade fever and cough and others being sent to the ER, admitted to the PICU to be put on CPAP and almost intubated. Although sad, it was interesting to see one disease state presented in so many different ways. Having a 4 month old son at home who had RSV a few weeks ago and needed to go to the ER one night, I was particularly interested.

Something I found difficult about pediatrics was GI complaints. It was frequent that a patient would present complaining of abdominal pain, vomiting, constipation diarrhea etc. Many times the patient themselves wouldn’t be giving the history as they were too young to articulate it or they weren’t able to speak or if they were able it was a very vague history. Additionally, children may complain often and Dr. Hurwitz told me about a study in which 3 main pediatric complaints, one of them being GI, were studied and found that most of the time it was benign. In my past 2 rotations, family medicine and ambulatory medicine, it was much easier to elicit the history of a GI complaint and those differential diagnoses are much more commonly found in adults rather than children. I had to change my thinking and switch it to a pediatric related complaint.

One part of the physical exam I improved greatly in is the ears. I always found it difficult to examine the ears even on adults but especially in children who are typically moving around or crying. I worked very hard on this aspect of the physical exam this rotation and feel I have made much progress. By the end of the rotation I was able to clearly visualize the tympanic membrane in most patients, detect fluid and the presence of an ear infection.

Naturally, there were a bunch of kids who were very difficult to examine as they wouldn’t stop moving, screaming or crying. At first I would shy away from this type of patient but as I gained more confidence in my abilities and skills in this setting, I felt more comfortable to instruct the parent how to hold the child and was able to be more aggressive at getting what I needed done. For example, there was one child who I needed to perform a respiratory panel on. He was kicking, screaming and thrashing around. I was able to instruct the mother how to hold him, brought in a colleague to hold his legs and I performed the nasal swab quickly and efficiently.

My perspective on pediatrics definitely changed after this rotation. I never thought I had much of an interest in pediatrics but after my rotation I have found that I definitely do! I found working with children to be enjoyable and rewarding. It required me to learn how to not only deal with children but with the parents of those children who are sitting right there and watching me perform my exam. Lastly, it pushed me to take my head out of the textbook and observe the child and their presentation, contemplate what’s most likely realistically and manage the patient sensitively and carefully (for example, not jumping to do imaging on a child with constipation and a benign abdomen and starting with a suppository perhaps and observation.) I will miss my time at Dr. Hurwitz’s office!

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