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Wednesday, March 20, 2013

Only one week left!!

I can't believe this is our last full week, it's flown by. The drive to work is going to be hard to beat when we return home.

We started at Port Maria on Monday and we were busy! Stephanie was in clinic and saw many rashes, infected scabies being the most common.  After consulting with each other and the physicians we learned they treat with a combination of permethrin, augmentin, and mupirocin. Scabies is not that common in our setting at home and seeing it infected is even less common. Once again our physical exam skills are being sharpened. I spent the day in the A&E and felt overwhelmed with the number and variety of things I saw. At one point I had a little girl in the observation area receiving IVFs, 2 children in the lab followed by X-rays, and 5 patients waiting outside. It felt like home and my multi-tasking skills were at their best. Perhaps the most challenging but revealing case was an 8 yo male who presented with complaints of HA, sore throat, anorexia, emesis, and abdominal pain for 1-2 days. He was febrile to 102.4 on arrival and did not appear to feel well. After a detailed history I learned he lacked URI symptoms and combined with my physical exam of cervical lymphadenopathy and an erythematous oropharynx I was leaning towards the diagnosis of strep pharyngitis. I had one hold up though, his abdomen was extremely tender and he demonstrated guarding in the RLQ without rebound. Upon questioning he kept pointing to his umbilicus when I asked where it hurt the most. We all know appendicitis in a child can present atypically but pain that started near his umbilicus, tenderness in the RLQ, high fever, anorexia, and emesis seemed a little too classic to let him go with just a script for amoxicillin. So I started delving into more history asking mom about his bowel habits, desperately looking for another cause of abdominal pain. He did exhibit some signs of constipation so I decided a KUB and a CBC could help me make a decision. A KUB to look for constipation and even free air if he had ruptured his appendix (unlikely given his exam) and an elevated white count, again to help rule out appendicitis. We were unable to get the CBC but the KUB showed constipation!! By that time he was running around outside and I felt very comfortable sending him with a course of amoxicillin for pharyngitis and mineral oil for constipation. Long story for a simple diagnosis but it goes to show that you can't ignore classic signs of something you can't afford to miss, appendicitis. It also shows that constipation in children is painful! Always keep it in your differential!

Monday nights at the resort are "Beach nights" and they make this wonderful dinner and have appetizers and drinks and music outside. We haven't yet participated in this awesome party but we did stop by and sneak a few of the appetizers. Our plan is to enjoy it our last Monday here which is this one upcoming.

On Tuesday we returned to Port Maria and switched our roles, Steph in the A&E and myself in clinic. Unfortunately the clinic had no available rooms for me so Steph and I shared a room. It was a busy day but we made the small space work. We saw over 30 patients together! Along with our ability to be efficient, our physical exams were put to the test. For visualization, we saw classic tinea capitis, diaper dermatitis, and more scabies. For auscultation, we heard many variations of wheezing as we had to frequently assess asthmatics after breathing treatments. For palpation, we assessed for fluctuancy of skin abscesses and I'm fairly certain we felt the "sausage" mass associated with intussusception. Other physical exam findings to note were strabismus and ptosis. It was a great day overall filled with a  huge amount of learning potential we definitely capitalized on. Today also brought continuity which is amazing. Steph and I were able to follow up with our little boy who's finger was lacerated after a grease pan had fell on it last week. We repaired it and prescribed augmentin and mupirocin along with recommendations to keep the dressing clean and dry. But little boys being boys that dressing came back as dirty and wet as you could imagine. There was pus overlying the lac when we removed the dressing but I like to think our antibiotics and mupirocin helped keep the infection at bay. We ended the afternoon as we had done last Monday but Steph and I switched roles. I tightly held the sweet little boy in a chair while Stephanie removed the sutures and redressed it. It was quite the tear-filled experience for our little guy as he remembered the procedure room from last week but he still liked us afterwards. He's coming back next Monday and continuing on antibiotics.

When we got back to resort we were exhausted from a full day and we spent an hour sitting by the beach just talking about the patients we saw that day, reviewing their presentations, and running our plans by one another. It's such a blessing to have time after a long day to really process what you did. The opportunity to process rarely, if ever, comes when working at home. I think most residents would agree with me. By the time you're off work you're often so exhausted that the only thing you can do is eat dinner, shower, and go sleep as you prepare for the next day, especially as we've switched to shift work.  I cannot convey how wonderful it has been to just sit and talk with Stephanie about medicine. I know from our weekend adventures that medicine may seem to be the last thing on our mind as we return to the resort every evening but that's honestly not the case. We both feel like we learned so much here and are appreciative for the much need down time.

We concluded the night with an amazing dinner at 8 Rivers and we even got fancy for the occasion. The food was delicious and filling and the waiter was shocked when we turned down desert. We then went to the main dinning area to enjoy some live music and found ourselves out on the dance floor in no time. From 'We are Family' to 'YMCA' we tore up the dance floor and made many new friends!

 Extremely blessed and thankful...S&S

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