During my pediatrics rotation site visits, I presented three H&Ps in total on a series of different pediatric complaints with some being pretty routine encounters and others more unique. For my first site visit, I presented two H&Ps. The first case involved a 5-year-old female who came in for a well-child visit with intermittent bright red blood on toilet paper after bowel movements. On exam, she was found to have a posterior midline anal fissure, which was the most likely cause of the bleeding. However, the case was also significant because the mother disclosed inappropriate sexual behaviors involving a 7-year-old male family friend at the father’s home. This made the visit more complex because, in addition to managing the anal fissure, it required appropriate documentation, safety counseling, referral for further evaluation, and mandatory reporting to CPS.
The second case involved a 4-year-old male who presented after two episodes of bilateral periorbital swelling and excessive tearing that had resolved by the time of the visit. The presentation was most consistent with a likely benign allergic process, although other differentials such as angioedema, viral conjunctivitis, nasolacrimal duct obstruction, and nephrotic syndrome were considered. This case helped reinforce the importance of asking detailed questions about possible triggers and red flags such as vision changes, pain with eye movement, fever, proptosis, respiratory symptoms, or generalized swelling.
For my final site visit, I presented an 8-month-old male with a history of respiratory distress syndrome at birth and prior RSV bronchiolitis requiring hospitalization who presented with cough, rhinorrhea, fever, decreased oral intake, increased fussiness, and increased work of breathing. His exam was concerning for bronchiolitis with respiratory distress, including tachypnea, nasal flaring, intercostal and subcostal retractions, abdominal breathing, coarse breath sounds, crackles, and diffuse expiratory wheezing. Due to his respiratory findings and history of prior hospitalization, he was referred to the emergency department for further evaluation, monitoring, and possible admission. Alongside this case, I also presented a journal article reviewing RSV prevention strategies, including maternal immunization, monoclonal antibodies, and other approaches aimed at reducing poor outcomes in infants.
The feedback I received during these evaluations was very helpful and well substantiated. For the first case, I was reassured that my documentation of the patient’s pain was adequate, but I was reminded that in younger children, especially around age 5, pain may be difficult to assess reliably. Because of this, it may be helpful to document an age-appropriate pain tool such as the FACES pain scale. I was also advised that when documenting CPS contact, it is important to include specific details such as the time CPS was called, the name or title of the person spoken to if available, and any case or reference number provided.
For the second case, I received feedback that it was good that I documented reviewing possible triggers, but I should be more specific in the chart. For example, instead of simply stating that triggers were reviewed, I should document exactly what was asked, such as: no new foods, medications, detergents, soaps, pets, or environmental exposures; no known seasonal allergies; and no family history of atopy. I was also reminded to clearly document specific dates and time intervals, especially for episodic presentations. In this case, because the eye swelling and tearing occurred in separate episodes, documenting the exact onset, duration, resolution, and recurrence pattern would make the HPI stronger and easier to follow.
For my third case, I was pleased to receive positive feedback and was told that the H&P had no major flaws. I was specifically praised for the quality of my respiratory exam, including the documentation of retractions, wheezing, crackles, and overall work of breathing. I was also told that my vital signs were appropriately documented and that my developmental and nutritional history was detailed and appropriate for the patient’s age. This feedback was encouraging because it showed that I was improving in my ability to document clinically important pediatric findings in a clear and organized way.
Moving forward, I plan to continue improving the specificity and clinical usefulness of my documentation. For pediatric pain assessments, I will incorporate age-appropriate tools such as the FACES pain scale whenever they can be used. For sensitive cases involving suspected abuse or mandated reporting, I will make sure to document not only the clinical findings and disclosure, but also the details of CPS communication, including the time of contact, the person spoken to, and any case number provided. For episodic complaints, I will be more intentional about documenting exact timelines, including onset, duration, frequency, triggers, and resolution of symptoms.
Overall, these site visits were valuable because they helped me recognize both my strengths and areas for improvement. I felt that my physical exams and assessments became more thorough throughout the rotation, especially considering this was my first experience with the pediatric population. At the same time, the feedback reminded me that strong documentation goes beyond simply trying to fit in a huge amount of information, but about including the most specific, relevant, and legally/clinically useful details. These experiences will help me become more precise, organized, and thoughtful in any of my future pediatric patient encounters.
