October 20, 2011

Learned on the pedatric rotation

It wasn't me! These are some of my learning points on my short pediatric rotation:
  • A children's doctor is a pediatrician not a pedestrian!
  • WBCs will rarely go higher than 20k for a pure stress reaction
  • Children have a much more exaggerated glucose response to stress, isolated hyperglycemia does not routinely require follow up
  • A tip for making an infant pee for urinary sample: put something cold on their stomach. Often it will be enough to just remove the diaper, the fresh air will do it!
  • Do not forget the rarely seen but important to know ddxs to strep A tonsillitis;
    • Vincent's angina: is a very aggressive necrotizing infection of the periodontal/gingival tissues commonly caused by Fusobacterium nucleatum or Treponema vincentii to name a few
    • Lemierre's syndrome: primary tonsillitis with severe sepsis following by thrombosis of vena jugularis. Most commonly caused by Fusobacterium necrophorum.
  • Ethmoiditis is an infection I had never heard of before but one of those that the pediatrician should have in his/her ddx list because of possible complications. I had subfebrile little girl with recurrent left orbital headache with discrete, hard-to-describe orbital soft-tissue oedema which we sent to the ENT for evaluation for E. This is the layman description: "Infection of the ethmoid sinus results in swelling of its mucous membrane, causing increased mucous production and nose block. Sometimes the ethmoidal infection can spread to the contents of eyeball and form pus collection. This condition is called orbital subperiosteal abscess."
  • A patient who has GIT symptoms secondary to erythromycin should try lesser but more frequent dosage e.g. x4 instead of the common x2 or x3
  • Betapred's (bethamethason) time of onset is 1-2 hours, peaks at 4h and duration of about 48 hours. Betapred can induce diabetes if used chronically but as usually the biggest worry is delayed growth.
  • A pneumococcal vaccine does not neccesitate change of antibiotics even if suspected infection with these (e.g. otitis), it will only take the tip of the infective burden but not prevent infections.
  • Capillary refill time seems to be a little overvalued for assessing circulation
  • Never ever exclude streptococcal pharynigitis/tonsillitis in the febrile child with normally looking throat on examination - you will one day have a positive Streptest even though you were certain there was no focus there!
  • Even the pediatricians are not really sure where to draw a line between bronchiolotis and bronchitis
  • Vasovagal syncope in a teenage girl is almost invariably because of stress!
  • SIDS statistics have changed a lot in twenty years and mostly thanks to academic research. The incidence is down from about 2-300 cases/year here in Sweden to 20-30, an incredible achievement where a single preventive measure (have infants sleep on back) is the single biggest factor.
The most important lesson learned though was the value of hearing a simple "I don't know" when asking senior colleges, an answer I fully respect and honor when appropriate. There is nothing more frustrating than hearing a long talk about everything but the original question and then finding out you are even more confused then when you asked the question. I will also this my self from now on!

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