Summary of evaluation
Present materials: two H&Ps, ten pharm cards and one article
In site evaluation, I present a patient with acute appendicitis. A 14 years old male child with immunizations up to date and no past medical history brought to pediatrics ED by mother with a complaint of RLQ abdominal pain x 1 day. Pain is described as sharp, constant, located in RLQ, 7/10 severity, with no radiation, accompanied with nausea and vomiting. Also 4 episodes of non-bloody and non-bilious emesis. Denies fever, chills, diarrhea, dysuria, sick contact, recent travel, diet change or trauma. Physical examination notable for RLQ tenderness, positive psoas and obturator. Labs noted for WBC of 17.64. The findings are most consistent with acute appendicitis. Patient was transferred to LIJ for pediatrics sonogram/CT and pediatrics surgical consult.
For the second case, I present a newborn baby with jaundice. A 3 days old female infant born at 40 weeks gestation via normal spontaneous vaginal delivery without complications, brought to pediatrics ED by mother with a complaint of yellowing of skin x 2 days. Physical examination notable for skin jaundice. Labs noted total bili 13.0 and indirect bili 12.7. These findings most consistent with physiological jaundice. NICU attending was consulted, and recommended to repeat bili level in two days, also phototherapy was scheduled. I also find an article talking about using synbiotics with phototherapy in full-term neonates. The article concludes that synbiotics with phototherapy has a significant effect on jaundice neonates, with lower level of bilirubin, shorter length of hospitalization, higher frequency of urine and stool.
Prof. Maida gave feedback for my H&Ps. For pediatrics, even though they are young, but sexual history should be included in the HPI, especially for patients who had abdominal pain. In addition, in the social history part, school and activity should be added. Furthermore, for review of systems, need to use patient’s language, not medical terminology.