1)H&P/Soap Note
2) Journal Article and Summary
This study is a systematic review of studies that aimed to get a more comprehensive description of Multisystem Inflammatory Syndrome in Children (MISC). MIS-C is a novel syndrome linked to severe acute respiratory syndrome coronavirus 2. The first published study of MIS-C was described in 8 children from the United Kingdom with hyperinflammatory shock in April 25, 2020. COVID was first discovered in December 31, 2019 in Wuhan, China.
It is important to understand MIS-C because there are currently no confirmatory diagnostic tests that exists. Multiple reports have described a 4-6-week delay between proliferation of local COVID-19 cases and surge in MIS-C cases. In a particular study with the greatest prevalence of COVID-19 RT-PCR positivity (69%), the authors noted that viral load was low in all patients and that serologic assessments were IgG positive for MISC. These lab findings suggest that there is indeed a substantial delay between timing of COVID-19 infection and onset of MIS-C symptoms.
In this systematic review, 8 studies were included with a total of 440 patients. Median age of patients were 7.3-10 years old and 59% of them were male.
Symptoms
The study found that the greatest proportion of patients had gastrointestinal symptoms ( 87%) followed by dermatologic mucocutaneous symptoms( 73%) and cardiovascular symptoms( 71%). Fewer patients reported respiratory symptoms (47%), neurologic(22%) and musculoskeletal(21%).
Therapies
There were different therapies used to treat MIS-C. Intravenous immunoglobulin(IVIG) was the most commonly administered( 76%) compared to vasoactive medication( 53%), steroids( 52%) and immune modulators(18%). 26% received intubation and 6% received extracorporeal membrane oxygenation.
Laboratory
Ferritin and d-dimer were elevated in 50% of patients. CRP, Interleukin 6 and fibrinogen were elevated in 75% of the patients which suggest an inflammatory state as the hall mark for MIS-C. Cardiac markers troponin, brain natriuretic peptide and N-terminal pro b-type naturetic peptide was also elevated in potentially 100% of patients in studies with cardiac inclusion.
Lastly, In relation to COVID-19, MIS-C has similar features to those found in Kawasaki disease (defined as inflammation in blood vessels throughout the body) so it is important to be able to distinguish the diseases. Approximately 80% of patients with Kawasaki disease are younger than 5 years old with median age of 2 years old. It also mostly affected Japanese children and other children of East Asian Descent. MISC- cases also exhibited greater prevalence of multi-system involvement, notably abnormalities like myocarditis and shock.
3)Site Visit Evaluation: My Summary
For my site visit evaluation, I had the opportunity to present 2 cases. My first case was of a 9-year boy who presented with intermittent dry cough and wheezing x 4 months. The patient reported that his symptoms have worsened, and he has been having cough and wheezing for 4-5 days weekly in the past month. The patient stated that his cough is worst at night as well. On physical exam, the patient was noted to have rhinorrhea, large pale boggy turbinate’s and wheezing. The patient was diagnosed with asthma and allergic rhinitis and prescribed an albuterol inhaler as well as oral prednisolone. I liked discussing this case with my evaluator Professor Maida because it was a great review of the asthma diagnosis with and duration/quality of symptoms which differentiate intermittent and persistent asthma. I was able to discuss some differentials including URI, Bronchitis, Pneumonia and Tuberculosis.
My second case was of a 3-year-old patient who presented with multiple episodes of vomiting, abdominal discomfort, nausea and fatigue x 1 day. The patients mother stated the symptoms began in the morning and his last meal the night before which was cereal with whole milk. The mother also reported that the patient had over 10 episodes of vomiting today, was able to drink water but has decreased appetite, has not been eating, was lethargic and had been sleeping more than usual. His urine output was normal, and he had a regular bowel movement the night before. The patient did not have a fever but was tachycardic with a heart rate of 129 and respirations of 22. His exam was normal except for dry mucous membranes. His rapid flu, COVID test, chest and abdominal x-ray was normal. His CBC revealed he was hyponatremic, had a CO2 of 14 and had an elevated anion gap of 23. The diagnosis was acute gastritis with dehydration. The patient was administered Zofran, given Pedialyte and started on IV fluids of NS bolus @ 50 ml/hr. After this, his labs normalized, notably the CO2 improved to 22 and anion gap to 13. This was a good review on dehydration in pediatric patients. I also was able to review the formula for hourly and daily fluid administration in pediatric patients.
4)Typhon Report
5) Rotation Reflection: Pediatrics
My pediatric rotation was at Queens Hospital Center. It was a great experience being able to learn and understand how to examine and treat pediatric patients in the clinic, emergency room and neonatal intensive care unit (NICU). One of the first things I learned from the providers was the importance of building rapport with pediatric patients. This was important because it helped with conducting physical examination with some children who may be afraid of the clinic setting. Often times, I saw the provider give the child a book to read, make sounds, play music or get down to the child’s level to build rapport.
I was not used to interviewing children regularly and I found the medical interview to be a little different from when interview adults in my previous rotations. Many of the patients I saw in clinic were there for well visits which consisted of going over medical history, performing a physical exam and updating the provider on any changes to the patient’s history. During newborn, infant and toddler visits, it was a rewarding experience to see the provider discuss with the parents about the child’s past medical history, vaccination history, growth chart and daily habits. It was a great opportunity for the parents to ask questions and even discuss ways of how they can work together to ensure the child is sleeping adequately, obtaining the proper nutrition, and reaching developmental milestones.I can recall a patient who was considered to have delayed speech for his age and another patient who would not respond to verbal cues telling him to go to a scale or go to his mother. I also learned from the providers how interviewing children in various stages in life can be different. For example, much of the history when gathering history from a newborn, infant or toddler will come from the parent and the physician can also assess how the child is behaving and interacting in the exam room for any developmental delays or medical problems. For a patient in high school, there are times when the parent is asked to step out of the room in order to ask the patient questions about any symptoms of depression/suicide, sexual history or drug/alcohol history.
My favorite clinic was the asthma clinic where I got to shadow Dr. Ting. He was awesome with the children and parents as he was able to establish rapport with his comedic and warm personality. He went over the child’s asthma medications and before the visit would perform a demonstration of how to use an inhaler. I thought this was great to give a demonstration and allow the patient to use the inhaler in the room to ensure he/she knew how to before leaving.
In the emergency room, some pediatric problems I countered with the providers were otitis media/externa, rashes, asthma exacerbation, flu like symptoms, gastroenteritis, musculoskeletal injuries and more. A memorable case I saw in the pediatric emergency room was of a 6-year-old boy who presented with LT elbow pain and did not want to move his elbow at all. Based off the mechanism of injury, the boy being lifted by one arm, the provider was able to tell that the patient’s injury was not as severe and diagnosed the patient with nursemaid elbow injury. This is when there is a subluxation of the radial head. The provider was able to perform a supination flexion technique in order to reduce the injury.
In the NICU I was able to observe a c-section. This was my first time observing the birth of a child and I was appreciative of the opportunity to witness the birth. I was able to see the nurses right after assessing the vital signs, skin tone and color of the child, have the parent cut the umbilical cord (and look for artery and vein), weigh the child, check for some reflexes of the newborn and more.
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