HISTORY AND PHYSICAL WRITE-UP

HISTORY

Identifying Data:

Full Name: JZ

Date of Birth: 07/13/2022

Encounter: 09/18/2023

Source of Information: Mother

Reliability: Reliable

Chief Complaint:

“His hand is swelling” x 3 days

History of Present Illness:

14-month-old male with no PMHx brought in by mother and presenting with red, warm, swollen, and tender right hand and fever x 3 days. Mother reports that patient presented to the ER on 09/06/2023 with similar symptoms, where he was diagnosed with cellulitis and discharged on a 4-day course of clindamycin. Mother reports that he finished the antibiotics and got better but symptoms started returning 3 days ago. Has been taking Tylenol for the past 3 days with temporary relief of fever. Denies known history of trauma or animal bite to area, puncture site, drainage, itching to area,

Past Medical History:

Denies any past medical history.

Immunizations: Up to date, has not received this year’s flu shot.

Past Surgical History:

Denies any surgical history.

Medications:

5 mL (160 mg) Tylenol taken every 6 hours as needed.

Does not take any daily medications.

Allergies:

No reported food, drug, or environmental allergies.

Family History:

Mother: 29, alive, healthy

Father: 30, alive, healthy

Social History:

Lives with parents, grandparents, and older sister. No recent travel.

Review of Systems:

General: See HPI.

Skin: See HPI.

Pulmonary system: Denies dyspnea, cough, wheezing.

Cardiovascular system: Denies edema/swelling of feet or left hand, syncope, or known heart murmur.

Hematological system: Denies anemia, easy bruising or bleeding, history of blood clots.

Endocrine system: Denies polyuria, polydipsia, polyphagia, excessive sweating.

PHYSICAL

Vitals:

-BP 95/65

-HR 133

-RR 28

-T 98.1 °F

-Height 32 in

-Weight 35 lbs

General:

Toddler well groomed, good height and weight for age, playing with mom. In no apparent distress when not being examined.

Skin:

Warm and moist, good turgor.

Mouth:

Mucous membranes pink and moist.

Lungs:

Respirations unlabored, no use of accessory muscles. Lungs clear to auscultation bilaterally.

Heart:

Regular rate and rhythm (RRR). S1, S2 present with no murmurs, S3, or S4.

Extremities:

Right hand erythematous, very warm to touch, tender to palpation. Non-pitting edema of 2 cm from right wrist to MCP joints. Decreased active range of motion of fingers of right hand. No fluctuance, abscess collection, crepitus, or break in skin noted. Capillary refill less than 2 seconds on all fingers. No edema, erythema, or tenderness in any other extremity.

ASSESSMENT

14-month-old male brought in by mother and presenting with red, warm, swollen, and tender right hand and fever x 3 days. Was evaluated in ER for similar symptoms 12 days ago with temporary resolution.

DDx

-Recurrent Cellulitis: Most likely, physical exam consistent with cellulitis. Initial symptoms responded to clindamycin. The ER did not take any cultures, it is possible the responsible organism is resistant or that oral antibiotics were insufficient.

-Animal Bite/Insect Sting: Can resemble cellulitis or may have been the original insult which was complicated by cellulitis. Unlikely to persist for this long, or to get better and then worsen. No puncture wound or bite barks noticed by mother.

-Systemic Pathology (Heart, Liver, Kidney, Thyroid, Allergic Reaction): Less likely due to localized area of symptoms.

PLAN

-send to ER

-blood cultures

-IV antibiotics (1^st gen cephalosporin)

-IV fluids

-imaging (X-ray, ultrasound)

-Tylenol for fever

JOURNAL ARTICLE

Efficacy and safety of intravenous ceftriaxone at home versus intravenous flucloxacillin in hospital for children with cellulitis (CHOICE): a single-centre, open-label, randomised, controlled, non-inferiority trial

The Lancet Infectious Diseases, 2019

Laila Ibrahim, Sandy Hopper, Francesca Orsini, Andrew Daley, Franz Babl, Penelope Bryant

This was a randomized controlled trial of 190 children aged 6 months to 18 years who presented to an Australian Emergency Room with uncomplicated moderate-severe cellulitis. Participants were randomly assigned to either home IV ceftriaxone therapy or inpatient IV flucloxacillin therapy (the standard of care in Australia). The primary outcome measure was treatment failure, defined as 1) no clinical improvement within 48 hours of the first dose or 2) an adverse event resulting in a change in antibiotics within 48 hours of the first dose. Secondary outcome measures included other adverse events and acquisition of antibiotic-resistant bacteria.

The authors found home treatment with ceftriaxone was associated with fewer adverse events than inpatient flucloxacillin therapy. In addition, it was found to be noninferior to the inpatient therapy in terms of treatment failure, complication rates, and repeat ER visits. Home therapy was associated with shorter lengths of stay in the emergency department.

A limitation of the study was that it compared two variables at once (i.e., it would be hard to attribute any benefits or harms to the location of therapy versus the antibiotics themselves).

The authors concluded that short-course ceftriaxone treatment at home is effective, safe, preferred by patients, and cost-effective for children with cellulitis. In addition, it was not associated with a significant increase in antibiotic resistance in previously healthy children.

SITE EVALUATION PRESENTATION SUMMARY

For the first site evaluation I presented two History and Physical write-ups and five Drug Cards. I presented a case of roseola and another of pinworm infection, both of which I saw for the first time on this rotation. I got mostly positive feedback on these two write-ups. One thing I was reminded of was the importance of treating close family members like siblings for pinworm. We also talked about the scotch tape test. For the drugs Professor Maida wanted me to know the MOAs, indications, contraindications, and adverse effects, but was less concerned about dosing, which was helpful to know when preparing for next time. At the second site visit I presented one more History and Physical, posted above, the attached Journal Article, and five more Drug Cards.

TYPHON POSTINGS

ROTATION SELF-REFLECTION

I really enjoyed my pediatrics rotation, more so than I thought I would. One thing I got really good at was doing blood draws. At first I was a little nervous because I knew that children have smaller vasculature and are more likely to struggle or resist. However, I learned how to instruct the parents to hold the child on their laps and secure their arms. As for the actual procedure, I found older kids and adolescents to be the easiest group of patients to find veins, much more so than the elderly patients I saw in family or internal medicine. I still struggle to find veins in infants however, and that is an area I could improve in.

Along the same vein (pun intended), I got a lot of practice giving injections. In fact, this is the first rotation where I gave subcutaneous injections. It was also the first time I gave intramuscular injections to a site other than the deltoid muscle. One problem I initially faced was that I was finding a small amount of blood and fluid from the syringe would frequently ooze out after I removed the needle. After talking with Dr. Arana and doing some online research, I learned about the Z-track method, where you slightly pull and hold pressure on the skin when giving an injection. This leaves a zigzag path behind when you remove the needle and release the skin. After trying this out, I saw a drastic decrease in backflow when removing the syringe.

At this location, I saw almost all of the patients alone before seeing them together with the doctor. I got a lot of exposure interviewing the local Hispanic community (and picked up a bit of Spanish along the way). I would estimate that more than half of the patients I saw this rotation were from the migrant population, with most of them being from Guatemala and Ecuador. I think this was a very good experience dealing with underserved populations. I also gained some familiarity with foreign public health policies. For example, many countries give the BCG vaccine at the same time as the second Hep B vaccine, other countries don’t immunize against varicella, and so on.

Another thing I liked about this rotation was that I got more exposure with the non-clinical side of healthcare. NYC has an online registry of children’s immunization records, which came in really handy when we had new patients. I got a lot of practice looking patients up there. I also learned more about how Medicaid and HMOs work, and how to look patients up with their various insurance companies. This rotation was also the first time I did prior authorizations.

PICO/CAT TABLE

Student	PICO #1	PICO #2	Pub Health PICO	OSCE Case	CAT Draft	Final CAT
Axelrod, Emily	In adult patients with acute pharyngitis, is a short course of adjuvant corticosteroids effective in reducing pain and symptom duration, as compared to placebo?	In adult patients with acute wounds, is topical honey effective in accelerating healing and preventing infection, as compared to traditional wound dressings?	In urban neighborhoods, do community gardens promote health by increasing access to healthy food and encourging physical activity?
Bak, Jessica	In adult patients undergoing bariatric surgeries such as gastric sleeve or RYGB is robotic surgery more effective compared to laparoscopic in terms of OR operative time, length of hospital stay and mortality?	Is normal saline more effective than lactated ringers when treating patients with acute pancreatitis in terms of SIRs, mortality and length of hospital stay.
Bowers, Abbie	In patients with a history of CKD who need CT imaging, what is the risk of developing an AKI secondary to IV contrast administration?	When performing intubations in the emergency room, does video laryngoscopy result in better first time success rates vs direct laryngoscopy?
Chong, Vin Kie	In patients with knee osteoarthritis (KOA), what is the overall efficacy of duloxetine as compared to no intervention or placebo?	What is the overall efficacy of aspirin for the primary prevention of cardiovascular disease (CVD) in patients with diabetes mellitus (DM) as compared to no intervention or placebo?	In people who inject drugs (PWID), does the implementation of needle and syringe programs (NSP) result in a significant reduction in the transmission of infectious diseases as compared to no intervention or placebo?
Exime, Azline	In patients who use condoms occasionally and have an IUD in place, does having an IUD increase the risk of sexually transmitted diseases?	In adults, does Ashwagandha (WS) help prevent and alleviate anxiety and stress?	In type 2 diabetic patients, is intermittent fasting more effective than daily caloric restrictions in improving glycemic control and decreasing hemoglobin A1C?		In adults, does Ashwagandha (WS) help prevent and alleviate anxiety and stress?	In adults, does Ashwagandha (WS) help prevent and alleviate anxiety and stress?
Fakir, Heba	In cases of threatened abortions, what are the results of administering progesterone?	In cases of preterm birth, what are the results of administering progesterone?	Do school-based mental health programs in underserved urban communities effectively serve as preventive measures for mental disorders?
Godoy, Mackenzie	In patients with complicated appendicitis who undergo a laparoscopic appendectomy, is abdominal drainage more effective in preventing pelvic abscesses compared to standard post-operative management?	In patients undergoing elective surgery, does immunonutrition decrease the risk of post-operative surgical complication compared to standard nutrition?	In obese adults, is self-monitoring via digital tracking an effective behavioral weight management intervention?
Grant, Nia
Hussaini, Immadullah	In adult patients who smoke marijuana, what is the effect of marijuana smoking on the development of lung cancer?	In female patients with menorrhagia, what is the efficacy of tranexamic acid compared to NSAIDs for the resolution of bleeding?	What is the effectiveness of pharmacist-led medication reconciliation in prevention of hospital readmissions?
Ishmael, Akram	Are pediatric ADHD patients being treated with methylphenidate (MPH) at increased risk for growth restriction?	Is honey a viable treatment option for pediatric patients with cough compared to cough medicines?	What were the mental health effects of mandated remote learning and lockdown policies on students?
Jacobs, Lily	In pregnant women with a breech presentation (P), does the use of anesthesia (I) during external cephalic version compared to no anesthesia (C) result in higher success rate of cephalic presentation and lower maternal and fetal complications (O)?	Among women of reproductive age who have been diagnosed with PCOS seeking fertility treatment (P), is letrozole (I) superior to clomiphene (C) as a treatment option for inducing ovulation and ultimately achieve pregnancy (O)?	In women under the age of 26, does the use of a digital interventions such as mobile apps or text message reminders increase HPV vaccination rates and series completion, compared to standard methods or no digital interventions?
Kaur, Navneet	In adults with COVID-19 infection, is zinc supplementation effective in lowering mortality compared to no intervention/placebo?	In adults with PTSD, is Prazosin effective in improving nightmare symptoms and improving quality of sleep compared to no intervention/placebo?	In adolescents, does the implementation of school-based pregnancy prevention programs significantly reduce the rate of pregnancies compared to no intervention or program?		In adults with COVID-19 infection, is zinc supplementation effective in lowering mortality compared to no intervention/placebo?	In adults with COVID-19 infection, is zinc supplementation effective in lowering mortality compared to no intervention/placebo?
Kwong, Jennifer	In patients with end-stage renal disease, is kidney transplantation a more cost-effective and better treatment option compared to long-term dialysis treatment?	In patients with varicose veins and chronic venous insufficiency, does endovenous laser ablation (EVLA) or radiofrequency ablation (RFA) compared to traditional vein stripping result in better clinical outcomes, lower recurrence rates, and reduced recovery time?
Lam, Tiffany	In pregnant women, does myo-inositol dietary supplementation prevent gestational diabetes mellitus?	Does vaginal antiseptic preparation before cesarean section prevent postoperative infections?	How effective is iron fortified foods in preventing and treating iron deficiency anemia in pregnant women?
Lerebours, Nicole	In geriatric patients diagnosed with mild cognitive impairment (MCI), does regular engagement in computerized/virtual reality cognitive training exercises compared to no cognitive trainingresult inimprovement in cognitive function and slowing of cognitive decline?	In older adults, does participating in a Tai Chi exercise program reduce the incidence of falls?	In the youth and young adult population, does Media Literacy intervention reduce body image dissatisfaction or related disorders?
Levine, Robert	Are lifestyle interventions more effective than placebo in managing obesity in elderly patients? Remake – Is Alendronate more effective than Denosumab in preventing adult osteoporotic fractures?	Is Donepezil more effective than Memantine at reducing cognitive decline in patients diagnosed with Alzheimer dementia?	Is the Montreal Cognitive Assessment (MoCA) more effective than the Mini-mental Status Exam (MMSE) in identifying dementia in the adult population?		Is Alendronate more effective than Denosumab in preventing adult osteoporotic fractures?	Is Alendronate more effective than Denosumab in preventing adult osteoporotic fractures?
Martinez, Rafael	In a patient that is experiencing symptoms secondary to Meniere’s disease, does intratympanic gentamicin therapy lead to greater symptomatic relief, in comparison to diuretics.	In a patient with acute cluster headache does the use of sumatriptan produce greater symptom relief in comparison to oxygen therapy.	In young adults, has the increase use of electronic cigarettes related to the rate of acute pulmonary infections/illness, in comparison to non-smokers.
McNussen, Amanda	In adults with treatment-resistant depressive disorders (P), does the administration of ketamine (I) compared to a placebo or standard antidepressant therapy (C) result in improved depressive symptom relief and long-term remission (O)?	In adult patients with antisocial personality disorder (P), does pharmacotherapy (I) versus cognitive behavioral therapy (C) decrease negative behaviors and increase social functioning (O)?
Newmark, Stevie	In patients diagnosed with schizophrenia, how does the use of long-acting injectable (LAI) antipsychotics with or without education, compared to oral medications alone, impact medication adherence and rate of relapse?	In adult patients with acute agitation in a psychiatric emergency setting, does the administration of ketamine compared to administration of antipsychotics result in a more rapid, effective, and sustained decrease in agitation while maintaining safety and tolerability?	In adolescents, does the implementation of school-based mental health education programs compared to no programs result in a significant reduction in suicide rates?
Pinsky, Shaindel	In patients presenting with a sore throat, is a rapid strep test as accurate as a throat culture in diagnosing group A strep pharyngitis?	In patients presenting with allergic dermatitis, are oral antihistamines more effective for symptom control when compared with placebo?	In adults, does nutritional labeling of calorie counts promote healthier food choices and consumption?
Rogers, Amanda	In patients diagnosed with pityriasis rosea, is treatment with antiviral agents effective in shortening recovery time compared to only symptomatic treatment or no treatment at all?	In pregnant patients with hyperemesis gravidrum, is Ondansetron more effective than Metoclopramide at eliminating nausea and vomiting symptoms?	In adult smokers, are electronic cigarettes more effective than nicotine replacement therapy in producing long term smoking cessation rates and abstinence?
Shah, Siddharth	For patients who are obese and prediabetic, does early pharmacological treatment such as Metformin help prevent the progression to diabetes when compared to no pharmacological intervention?	In patients with chronic kidney disease who are not on dialysis, can a low-protein diet prevent the transition to dialysis therapy?	Do school-based programs that offer condoms decrease the prevalence of STDs?		For patients who are obese and prediabetic, does early pharmacological treatment such as Metformin help prevent the progression to diabetes when compared to no pharmacological intervention?	For patients who are obese and prediabetic, does early pharmacological treatment such as Metformin help prevent the progression to diabetes when compared to no pharmacological intervention?
Simon, Andrew
Tekalign, Isaiah
Winter, Hannah	In patients with community acquired pneumonia, does the use of ultrasound compared to traditional imaging (ie CXR) result in better diagnostic rates?	In adult patients following cardiac arrest, is maintaining a normothermic temperature effective in improving morbidity and mortality compared to traditional targeted temperature management (ie hypothermic range of 32-24C)?	For adults with a history of  hypertension, does the use of mobile apps / digital intervention improve medication adherence and patient outcomes compared to no intervention?
Yeasmin, Tamanna	In adult patients with osteoarthritis, how does exercise therapy compared to NSAIDs or other analgesics help to improve pain and function?	In adult patients with COVID-19 infection, does the use of remdesivir help to decrease morbidity and mortality compared to no treatment or placebo?	In the adult post-stroke population, is the use of selective serotonin reuptake inhibitors (SSRIs) effective in the prevention of post-stroke depression (PSD) compared to no treatment or placebo?