Archive for July, 2009

Case of the Week: Premature Pubarche


I know I fell behind, but thing got kinda of busy, and well, I let myself start to slack a little bit. But I am all good now.

So, the winner for this week ( or the past ten days) is actually a case that I saw today in my continuity clinic. My last patient of the day…and what is the chief complaint? Unusual hair growth. And I am just like…well FUCK.

So I go in to this this 11 month of Caucasian female, and she has about 5-10 course dirty blond pubic hair. No breast buds, no discharge, no axillary hair, no unusual odors, no family history, just pubic hairs in an 11 month old little girl. So, I go and tell my preceptor, and she is pretty much like…well FUCK. We order a bone scan to try and estimate bone age, and we get LH and FSH levels. Which really, upon further reading when I got home, we should have ordered DHEA -S levels.

The good news is that premature pubarche, which is the isolated appearance of sexual hair before the age of eight years in girls and nine years in boys.  Is typically a begnine finding. It is also more common in girls. So if the bone scan comes back normal, then she will be ok. If not, we will really should order the DHEA-S levels because that will give us more information than the LH and FSH levels and take it from there.

But yeah, pubic hair in an 11 month old girl is not something anyone should see, and something I didn’t think I would ever get to see. What a great teaching case.


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“Lets Just Bomb The Kid”


Words  I never thought I would hear as a Pediatrican, but here they were tonight on my fourth night of call.

Now, you may wonder why we would want to “Bomb” a child. Well, here it is.

So when a child comes in, and the are really fecally impacted. I.E fully of shit, literally. We clean them out with an Enema. The enema of choice is really up to the doctor taking care of them. My enema of choice is Go-Lytely, others prefer Milk of Molasses or some other concuction. Well, this particular doctor that admitted a patient liked the Pole-EE Bomb! This was a new one on me.

So what is the Pole-EE Bomb you may ask? Well it is a rectal supository of gastrografin, mineral oil and normal saline…and AWAY we go. So, if you are ever hanging around a Peds ER, or something like that, and they say they are going to bomb a kid. Rest assured, this is most likely what they are talking about.

P.S for this particular patient tonight. If the bomb hadn’t worked, I would have had to manual dis-empact this charming 18 year old boy. Thank God for the Bomb!

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Wait…What Happened?!

girl and dog

So, this week, I actually have two anecdotes that fit into two different categories. I have one “case of the week” and one “You named your kid WHAT?”

 Case of the week: This one actually came overnight and is a plastic surgery case that we are simply consulted on. A 9 year old female bit her dog in the ear, and the dog bit her back…in the face. But wait there is more. The dog bit her lip off, mom throws the lip in the trash can and then brings her to the ED. Guess she was tired of hearing her daughter’s lip. (Please laugh, I worked really hard on that one). But no worries, this story has a happy ending. Plastic surgery had the mom go back home and fetch the lip and they were able to re-attach the lip. As for the Dog, well, his ear is ok and the family is not blaming the dog.

 You named your kid WHAT?: Mister Morris IV. Oh, you want to know what his first name is? His first name is Mister. Yes folks we have a Mister Morris the Fourth. Sigh. Yes, the family was black.

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Case of the Week: Summer Penile Syndrome


I am going to try to do this every seven days. Talk about a WTF case that I come in contact with. So this week, we have Summer Penile syndrome. I know what you are thinking. I must have made this shit up, but no, no I didn’t. This poor little kid comes to the emergency room with a rash that started on his face, but then quickly spread to the rest of his body. He penis and scrotum was HUGE red, and angry.  We consulted Urology and Dermatology. Urology because the poor guy hadn’t peed in two days, and dermatology for obvious reasons.  Dermatology throws out a bunch of things that make sense, and then are like…well, it could be Summer Penile Syndrome. So Urology (who don’t end up cathing him because as soon as we admitted him to the floor he peed) in thier note also say, yes, Summer Penile Syndrome is high on the differential.  And the rest of us are like….WHAT?

So, what is summer penile syndrome you may ask? It is a hypersensitivity to chigger bites. Long story short, little boys run around in the summer with shorts or pantless, and roll around in the grass. Get bit, and well, you can figure out the rest.  Did my patient infact have Summer Penile Syndrome? No, not in the least. Actually, I shouldn’t say that. It was more likely that he had Rhus Dermatitis, but we don’t really know what the cause of his rash was.  We gave him fluids, steroids, and antibiotics and he got better.

For more information on Summer Penile Syndrome. Please click the following site for related journal articles.

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I walked into the hospital  at 6:15am Wednesday, July first and I walked out 11:14 Thursday, July second.  The good news? I was able to still walk, and I didn’t cry. My first day (and a half) of being a doctor. I went from the “OH SHIT I can’t believe this is starting” to the “OH SHIT I hope I don’t kill anyone” to the “OH SHIT I have no idea what is going on in my head because I haven’t slept for about 28 hours!!”

The crazy thing is that the utter feeling of pure unadulterated exhaustion didn’t hit me until I walked out of the hospital. It’s like the hospital is this fortress of energy where time stands still. Or, it could be that I was so busy and stressed that I just didn’t have time to be tired. When the rest of the team arrived at 6:30 this morning I was so cracked out on pseudo energy that I am surprised I was able to present and stand by my plans this morning. Seriously.

Ok, so lets talk about what one does for damn near 30 hours in the hospital. Well, when I arrived at 6:15am, I went through the process of seeing my patients, finding out what has been going on with them, and pretty much trying to get a handle of their medical history and why they are currently in the hospital and what I should be doing with the team to get them the heck out, while at the same teaching third year medical students and getting my notes done. This lasted till 9am, which is really a travesty since I am going to have less time starting well…tomorrow.  Then at 9am we round with the hematology and Oncology team. This is the scary part of the morning because our attending is the Tank! She is  Russian, and fierce…and no, not in the ANTM way, in the I am going to eat your face off if you are not prepared way. Luckily, I didn’t have a hem onc patient, so I could just stand back and watch the disaster occur as my poor fellow intern was made an ass of, because (thru no fault of her own) she was not prepared for the Tank.

Then from 10am-noon, we round with the general pediatric attending who is in charge of the rest of our patients. These patients have a variety of diseases including Cystic Fibrosis, Reflux, Gasteroperises, Cellulitus, Rash of Unknown Cause and a variety of other causes. I must say though I was in no way perfect during rounds, I think I held my own pretty well. I had all my information ready, and I had synthesized a pretty good plan of action that the attending agreed with, and I did a good job of getting my students ready. So, at this point, the day wasn’t too bad.

From noon-4:30 is when the actual work gets done. This is when we carry out the plans we talk about during rounding, we call our consultant physicians,  getting labs and other procedures , re-checking on our patients to make sure they are still stable and discharging patients we decided that we had fixed enough to go home. We also got one new admission during this time.

At 4:30, my fellow intern gave me updates on her patients, and what things needed to be done for them overnight, as what things I should watch out for, then she was outa there. At five, my senior night float resident came, and the rest of the day shift left. We had about an 2 hours of peace where we did night rounds, and got dinner before the phones started ringing and pagers started going off. We had a new admission, so I went to the ED with the medical student who was lucky enough to be on call with me. We evaluated the patient, history taking, P.E exam and all that, came up with a plan, then went over it with the senior resident and called the attending. By the time we got the patient to the pediatric floor, got orders and notes written, it was about 12:23am. I worked on my notes for a little bit then went to my room to lay down. at 12:31 my pager goes off, and there is another new admission at the ED.

This one should have scared the crap out of me with the history of this patient. But I will be honest, I am still in-experienced, and I am still trusting my eyes and ears, and not planning beyond that. That was the error I made that morning, as well as not going with my gut. Thank God it didn’t turn out to be a fatal one, but still scared me this morning during rounds. Long story short, I should have ordered a lumber puncture, but I didn’t think the kid needed one, and neither did the attending when I called her with the plan.  The kid was stable overnight and nothing happened, but this just points out why we have multiple rounds. To always evaluate and re-evaluate the patient and the plan.  Anyways, by the time we got that kid tucked in for the night, it was around 3am. I worked on my morning notes, then went to lay down at 3:30, I figured I could get a good 2 hours before going to see my patients at 5:30. I was wrong one of the babies spiked a fever at 3:42, I said to watch it. Another baby started throwing up at 4:02, I went to adjust his feeds.  The first baby spiked another fever at 4:33. At this point, I woke up my senior and went to go evaluate this kid in person cause I was nervous about this one. He had been fussy all day and now he was spiking fevers. I had them do blood, urine cultures but NO lp, and started him on some antibiotics. I called the attending and she was cool with this.  By this time it was 5:23, so I started checking on the rest of my kids

So, yeah, this was my first 30 hours. The rest of the team came trickling in between 6:15-6:30 this morning, I briefed them on what happened overnight, and we started the day over again. During general rounds, we saw my patients first so I could be out of there before noon.

What can I say about my first day? Even though I was having OH SHIT, shits, and I was stressed, and didnt sleep at all, I not only love what I am doing, I am looking for ways to improve and keep on learning for my patients.

Ok that is all I gotsa say…that is until I go back at 6:15 and do it all over again!! My next call is Sunday July 5th. Stay tuned!

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