Rotation Summary

My experience on my pediatric rotation was very positive. I got a lot of experience preforming physical exams, presenting cases to preceptors and together developing a plan. I am happy I got the chance to continue practicing presenting to attendings, as that was something I felt I needed to work on after my emergency rotation.  In addition, I got to play an important role in educating patients and parents about different conditions and the proposed treatment plan.  I also think I did a good job reassuring patients during an uncomfortable part of the physical exam or during a procedure which is more of a challenge in pediatrics.  I feel like I am transitioning into taking a more active role which I think is appropriate at this point in rotations.

Different from my past rotations, I got to work with different specialists. I was able to learn more about the specialized management for patients.  This gave me better insight on treating patients with endocrine issues, severe asthma, and cardiac abnormalities.  I was also able to spend time discussing these cases with the provider which I appreciated.  In addition, I got exposure to more critical patients in the NICU.  I was happy I had the experience being exposed to more specialized fields and delve into topics I had more preliminary knowledge of.  I hope that these experiences will give me more insight into treating patients with similar conditions on future rotations and in practices.

There are a few things I hope to improve upon in the upcoming rotations.  I was not able to do as many procedures.  I think sometimes I was reluctant to volunteer, which I am going to try to do a better job of on my next rotation.

Here is a log of the patients I saw Case-Logs4

Site Evaluation

Reflection 

Overall, my site evaluations were a good learning experience.  For my first site evaluation I presented a history and physical of a 16-year-old female with a complaint of hematuria and abdominal pain for three days.  Her urinalysis results indicated that she had cystitis and she was treated with Keflex. I thought this was an interesting case to present because at this age and especially with a complaint of this nature, eliciting a sexual history is a crucial part of assessing this patient properly.    In addition, it was appropriate to order a pregnancy test in order to rule out an ectopic pregnancy.

At my second site evaluation I presented an article regarding antibiotics appropriate for the treatment of urinary tract infections in pediatric patients.  This was helpful because there was some discussion at the previous site evaluation regarding the appropriate treatment.

Some feedback I got was that I can do a better job with my pharm cards, which I intend reviewing more prior to my next site evaluation. Overall, I think I’ve improved on my ability to present the pertinent details of the case.

Here is the history and physical for the patient I presented HP Rotation 4.

Journal Article

At my final site evaluation I presented an article regarding the antimicrobial resistance in organisms causing UTIs in pediatric patients.

Summary

Predictors of Antimicrobial Resistance among Pathogens Causing Urinary Tract Infection in Children

This study was aimed at determining which pediatric patients are more likely to develop urinary tract infections that are resistant to narrow-spectrum antimicrobials.  Data is compiled from two prospective, multicenter studies in which clinical and demographic characteristics were documented to determine factors associated with resistance to narrow-spectrum antimicrobials.  This included 607 patients with vesicoureteral reflux in the Randomized Intervention for Children with Vesicoureteral Reflux trial and 195 children without VUR in the Careful Urinary Tract Infection Evaluation.  33 children were excluded due to missing data.   Predictors measured were age, site, organism, sex, race, ethnicity, presence of BBD, use of antibiotics in past 6 months, number of UTIs, febrile vs. afebrile UTI and symptom duration.

Overall sensitivity to first-generation cephalosporin and nitrofurantoin was high when treating E. coli, and sensitivity to amoxicillin was low.  There was lower sensitivity to Bactrim in non-E. coli pathogens.  Sensitivity to second-generation cephalosporins, third-generation cephalosporins, gentamicin, tobramycin and quinolones was > 90% for both E. coli and non-E.coli organisms.

The risk of resistance to cephalosporin and amoxicillin in uncircumcised males was 3x that of females.  Receiving one dose of antibiotics in the past 6 months increased risk of resistance to first-generation cephalosporin and amoxicillin, however receiving 2 or more antibiotics did not alter risk of resistance.  Greater risk of resistance to trimethoprim-sulfamethoxazole was found in Hispanic patients.  Patients from Washington D.C. demonstrated high rates of resistance to amoxicillin and trimethoprim-sulfamethoxazole.  Rates of resistance for VUR grades were only significant for nitrofurantoin.

Renal involvement- second or third generation cephalosporin, resistance to other antibiotics is high and tissue concentration of nitrofurantoin not adequate enough.  An afebrile child with no renal involvement can be treated wit first-generation cephalosporin, probability of resistance to Bactrim and amoxicillin is high and nitrofurantoin can cause GI symptoms.

Limitation- not representative of all patients with UTIs, majority of patients had VUR. However, aside from nitrofurantoin, VUR not associated with narrow-spectrum antibiotics.

In children with risk factors for infection with drug resistant organisms, it is more effective to treat with broad spectrum antibiotics, while narrow spectrum antibiotics can be used to treat children with low risk of developing drug resistant infections.

Here is the original article