Being at the children’s hospital for the past few weeks, especially coming off a month of vacation, has been absolute torture. Just…give…me…one…sick…patient! PLEASE! I know that sounds horrible to ask for, but when there are 5 residents covering 13 rooms, and it’s yet another kid with fever, but running around the room like a tornado, it feels like pulling teeth one agonizing patient at a time. The challenge here, and the thing that scares me a little, is that 95% of these kids are totally, absolutely, no doubt about it fine. But some of these other little buggers, there may be some little thing, some little harbinger of impending doom, that if you don’t pick it up, these kids might not do so well. And that’s really no different than adult medicine when you think about it, but still, they are kids, and no one wants to do harm to a 1 year old. So the challenge has been to stay sharp, to do due diligence on each kiddo, get them all undressed, look em’ over from head to toe. Ask all the questions, to each patient, each time, even though, the majority of these kids can be discharged from the doorway.
So last night, I was seeing a 4 year old, mom brought her in for cough and congestion and some dry skin on the face. Clear as day, the kids got a simple URI, but I got the kid undressed anyways, just to make sure she wasn’t retracting or anything like that. And when I did, I noticed two 4cm marks on her forearm.
“Sweetie, what happened to your arm?”
“My mom hit me with a belt!” (all smilely when she said it too). And of course mom is sitting right there. Mom openly admitted to it, giving the reason that she has six kids, lost her cool one day, it only happened once, she feels horrible, and has enrolled in parenting class. Fine. Still gotta fill out my paperwork and call child services.
I’m not trying to say, oh look how great my H&P is, rather, just how easy this would be to miss. I’ve been really trying to do my H&P’s the same for most everyone, adults and kids, regardless of what the complaint is, same set of basic questions, same basic physical exam maneuvers, and then focus and expand based on the complaint, just to make it habit, so when it’s 4 am and I’m dragging my feet, habit will kick in and make me check these things that I might not bother to otherwise, as was the case with this kid.
(plus, the set of questions I ask, hits 10 systems on the ROS, two per system, so that way I’m not actually committing medical billing fraud when I document my level 5 chart! Bonus!)