Textbook Diagnosis

It's in the books. There is something fascinating when you actually get to see a "textbook" case in the clinic. Before medical school, I would have thought disease states followed some text written description or at least would present as we are taught. They don't and that is what makes medicine a "practice". Diseases don't do a whole lot of reading in their spare time.

Learning from the Patient

Earlier this month, a young child was brought to the clinic with decreased appetite and oral sores that the mother had noticed for a couple days. My initial exam suggested this was more than oral ulcers. Thinking back to the diseases with oral lesions I was excited to look for more skin changes on other parts of the child's body. One small vesicle on the palm and one on the foot confirmed my suspicion of hand, foot, mouth disease (HFMD). It was exciting to see what the books had described, albeit a mild case. On follow-up examination days later, I reached for the child's hands to see what changes could be seen, there were none. Mimicking my examination, the child's sibling did a self-exam and quickly realized he too was affected. Once a family supporter and now a patient, the sibling actually had a worse case of HFMD that would have gone undiagnosed if he wasn't present.

In a sense, the diagnosis was rewarding knowing that somewhere in my mind was stored the details to help my patient. With the vast amounts of knowledge we are expected to retain and the impossibility of doing so, I am willing to celebrate the small successes. Seeing textbook cases helps confirm my understanding of the many documented pathologies we are expected to understand. Written details are reinforced by touching, seeing and hearing the real thing in person. At least I am making progress in the right direction...and washing my hands a lot more frequently.

Question of the Week

A parent brings in their 4 year old child with what appears to be hand, foot and mouth disease. You know this is commonly associated with the Coxsackie A virus and want the parents to be aware of possible complications that may arise including which of the following?

A. Encephalitis
B. Renal Failure
C. Cardiac arrhythmias
D. Myalgias
E. Vision impairment

Answer & Explanations

Pediatric Medicine

Likely due to language disparities, my less-than-five-year-old patient sat quietly on the examination table patiently waiting for me to start. She was smart and well-versed in the way of the doctor's office. As I approached, she knew when to open her mouth, brush her hair back for access to her ears and when to take deep breaths for adequate pulmonary auscultation. Finally finished with my exam, I returned to my documentation and in her best thespian performance let out a wee little, "a-choo," followed by a finger to the nose for good measure. [Picture: Before The Shot, by Norman Rockwell]

Child's Play

This month on pediatrics I am observing all kinds of lost treasures from childhood. From true emotions that come out in smiles, laughter and screams which somehow get tucked away when we grow older to naive playing with other people never met, ringing bells just because they are there and making sounds for no other reason than to entertain the thoughts floating inside one's head. It brings thoughts of Patch Adams gallivanting through a pediatric unit striving to see just a glimpse of a smile.

I had to laugh a little when another patient in the middle of their numerous vaccinations screamed in horror, their mother encouraging manners and to say thank you. What child wants to show appreciation for a shot and multiple at that?! Nevertheless, it brought a smile to my face when the little voice, through tears, cried out a profound, "thank you!"

Children are trying to be good even though their world revolves around them sometimes. It bothers me when their parents get cloudy vision and choose to refuse care that would easily remedy problems because they lack time or money. Taking your child to the emergency department is not just a suggestion by your doctor, it is sound medical advice that merits following. It makes me wonder why they brought the child in the first place if all they are going to do is ignore our recommendations. So who is the egocentric one now? Clearly, parents are responsible for their child's well-being. Maybe it's time for parents to have their own time out and come to their senses.

While I observe their behavior and character, I wonder what has happened to the child in me. Have I suppressed it so much that it can no longer come out to play or do I encourage its development in the hopes of a happier, healthier me?

Question of the Week

While doing a routine well-child exam you notice your 7 year-old male patient has freckles in his axilla and multiple café-au-lait spots on his torso; 3 anteriorly and 4 posteriorly. There is mild genu varus, no scoliosis and no vision abnormalities. What is the most likely condition this patient has?

A. Lesch–Nyhan syndrome
B. Henoch–Schönlein
C. von Recklinghausen disease
D. Chediak Higashi syndrome
E. Tuberous sclerosis

Answer & Explanation

Pediatrics

There is something about the contrasting palm trees against the Las Vegas sky that makes this building look so inviting. It might be compensating for the fact that if you are a youngster, you have a good chance of getting shots here.

Youthful Medicine

The waiting room's row of low-rise chairs and toys keep the children engaged before their visit. Patient rooms are decorated with animals and cartoonistic art. This clinic is using whatever it takes to keep the young patients happy long enough to be examined from toe to head.

The change from a patient population that is older in years to one that commonly has only days or months has been a drastic one. I have to explore new methods of examination to keep the children from crying incessantly before I even touch them. Fortunately, my preceptor is a veteran in the field and has taught me some of the finer points of the pediatric approach. Although I must say that any child being circumcised is bound to have some aggression towards their doctor.

For the most part these little patients are generally happier and less demanding than the adult population. Their looks of intrigue mixed with fear are something to appreciate and more often than not, they are bewildered by the technology of bright lights and shiny objects. If they can brave the barrage of the doctor's exams, nurse's shots, and foreign environment the reward of a sticker is usually enough to encourage a return visit.

This will certainly be an interesting month. Since the pediatric population will be encountered in the majority of medical fields, it is imperative to hone my clinical skills now. I just hope we don't run out of stickers any time soon. 

Question of the Week

You went to visit your friend from college who recently had a baby. She named him Johnny. As the mother was gently letting you hold Johnny, he appeared really anxious and started crying once you reached to hold him. Johnny's age is most likely to be:

A. 2 months
B. 3 months
C. 5 months
D. 7 months
E. 4 years

Answer & Explanation