Mohammad O. Hussaini, MD
As a USMLE taker and a physician, you will need to diagnose and work-up a yellow baby. Jaundice (yellowing of the skin, eyes, and mucous membranes) in the pediatric population is either normal (physiologic jaundice) or not normal (pathologic jaundice).
Jaundice basically occurs when there is a high level of bilirubin in the blood. When blood levels of bilirubin exceed 5 mg/dL in the neonate or 2 mg/dL in others, the characteristic yellow discoloration of jaundice is observed.
Bilirubin is a by-product of red-blood-cell degradation. Normally, this bilirubin is conjugated in the liver and secreted in the form of bile into the small intestine. When there is either an increased production or decreased elimination of bilirubin, jaundice occurs.
Physiologic jaundice occurs in about half of all babies. This type of jaundice sets in one to two days after the child is born. Bilirubin levels generally peak at 12–15 mg/dL, three to five days after birth. By the end of the first week of life, levels return to normal. Reassure parents of children with physiologic jaundice that this is normal and the child should be OK by the end of the week. One should keep in mind, though, that neonatal illness could prolong physiologic jaundice. If the jaundice persists, treatment may be indicated to avoid complications.
Pathologic jaundice can be due to both intrahepatic and extrahepatic causes. Whatever the etiology, just remember that any jaundice present at birth is pathologic! Common causes of neonatal jaundice include cholestasis from any cause (bacterial or viral hepatitis, liver cancer, Wilson’s disease, cirrhosis, etc.) and extrahepatic obstruction (choledocholithiasis, pancreatitis, biliary atresia, etc.). In the latter case, the neonate can’t secrete the conjugated bilirubin from the liver, so there is buildup of conjugated bilirubin in the bloodstream. When formulating a differential for a neonate in particular, don’t forget the congenital disorders of bilirubin metabolism. In Crigler-Najjar syndrome, there is a glucuronyl transferase deficiency (Type 1 is bad, and kids die by age one). In Gilbert’s syndrome, there is a defect in the same glucuronyl transferase enzyme. And in both diseases, one will find an increase in unconjugated bilirubin. Two more congenital disorders that you should be aware of are Dubin-Johnson and Rotor syndromes. In both, there is an increase in conjugated bilirubin (implying there is a problem with excretion). Though all of these syndromes can cause jaundice, none require treatment, other than Crigler-Najjar.
There are three more causes of jaundice that you need to keep in mind for the USMLE. These should be high-yield. First is breast milk. Breast milk jaundice usually sets in about two to three weeks postpartum. Tell the mother of the jaundiced child to stop breast-feeding and to switch to a bottle until the jaundice resolves. Later, she can restart breast-feeding. Second is Rh incompatibility. If a child is born jaundiced, remember to get a Coombs’ test (direct and indirect), Hb, reticulocyte count, and peripheral smear. Treatment for hemolytic disease of the newborn (erythroblastalis fetalis) involves blood and exchange transfusions. The third cause of jaundice is drug-induced. Sulfa drugs displace bilirubin from albumin, so don’t give them to infants.
So, why do we get so worked up about neonatal jaundice? The main concern with jaundice is kernicterus. High levels of unconjugated bilirubin in the bloodstream cross the blood-brain barrier and cause brain damage, especially to the basal ganglia and hippocampus. The damage can manifest itself as mental retardation, cerebral palsy, deafness, weak muscle tone, lethargy, and seizures.
Work-up for neonatal jaundice first includes a good physical exam. Look for any abdominal pain or neurological symptoms. Get a bilirubin level (conjugated and unconjugated, of course), Coombs’ test, Hb/HCT, reticulocyte count, liver-function tests, albumin, and a peripheral smear.
There are two main treatments for unconjugated hyperbilirubinemia: phototherapy and exchange transfusion. Phototherapy is for rapidly rising or persisting bilirubin, or bilirubin greater than 15 mg/dL. Don’t choose exchange transfusion unless bilirubin levels are greater than 20–25 mg/dL and phototherapy has failed. Conjugated bilirubin treatment is targeted at the underlying disorder.
Beginning Your Pediatric Clerkship
By: Valarie Stricklen, MD
A pediatric clerkship is like no other. All the studying in the world cannot prepare you for what you will come across in the pediatric office or inpatient service. Many people say, “Children are just little adults.” On the contrary — they are very different in their attitudes, personalities, and even medical conditions. Pediatrics is also unique in that you essentially have two patients: the child and the parent(s). Are you scared yet? Don’t be! Pediatrics can be your favorite and most enjoyable clerkship, if you are prepared.
The expectations for a third-year medical student rotating through pediatrics are quite simple:
- Do what is asked of you (history-taking, note-writing,etc).
- Be prepared for rounds, seeing patients, etc.
- Read about your patients.
- Act in a professional manner.
The above expectations are quite similar to those of any third-year clerkship.
So, what makes pediatrics different from the others?
One difference applies to your history-taking technique. Obtaining a medical history from an adult is easy. You ask him or her questions and they give you answers. However, in pediatrics, your patient is often unable to speak in intelligible sentences, or even to understand you. It takes great finesse to try to obtain an accurate history from a three-year-old who is running circles around your chair while screaming at the top of his lungs. Often, distraction can be your best friend. Giving the child a book or showing them your stethoscope while you speak to the parent gives you that much-needed peace and quiet. It is important to keep in mind, however, that if the child is old enough to understand your questions and answer them, she can be a great resource. Only she really knows what her “ouchie” feels like, or how long it has been going on.
The content of the medical history is different, as well. The child’s brief medical history is only one part of the information we need. In pediatrics, we will ask questions about birth history, immunization status, developmental history, and the psychosocial history of the entire family. Learning the essentials in taking a thorough pediatric history, and being able to write information in H & P form, is key. This can be a daunting task, but understanding the basics and developing a systematic approach will make it easier and much more enjoyable. Keep in mind that it takes practice to be able to do all of this efficiently, so do not be discouraged if your attending or resident steps in every once in a while. Time is of the essence, and we sometimes need to keep things moving.
According to the Merriam-Webster dictionary, the definition of professional is one “exhibiting a courteous, conscientious, and generally businesslike manner in the workplace.” While this is an accurate description, professionalism in pediatrics requires much more. Would you ever see a “professional” playing with toys on the floor of an exam room, reading a book out loud using cartoon voices, or playing peekaboo and laughing hysterically? That is the life of a pediatrician. On your rotation, you will discover that we are looked at with respect and admiration, but we still have fun every day. That same attitude is expected of you if you wish to excel in your clerkship. Be prepared to act like the prototypical professional — but remember, flexibility and playfulness are job requisites, as well!
Valarie Stricklen, MD is an Assistant Professor of Pediatrics, and Pediatric Clerkship Director at the University of Toledo College of Medicine.
Survival Tips for the Intern
By: Loan Trinh Kline, MD
You finally matched into residency, it is July 1st… and you’re the doctor. It’s a big responsibility, and you’re scared and clueless. Don’t worry! Take a deep breath — everyone goes through this. Here are the tips I’ve learned along the way to help me survive my intern year.
#1 – Ask. Simple as that. When you don’t know a medication dosage, where to go to get something, or how to do something, just ask! Ask your senior (they are there to help you) or an attending (if your senior is nowhere to be found). Ask a nurse, unit secretary or a colleague. They have been doing this for a long time and would rather have you do something right the first time. Plus, this shows you’re interested and makes things a lot easier.
#2 – Make lists. Have a list of phone numbers, or know where to find numbers of all your ancillary services or consults. Most of the time, the hospital will have a website where you can obtain these numbers. Know the number for the lab so that you can call them to ask what media/color tubes you need for your labs. Know the number to the pharmacy because, trust me, they would rather have you call them to ask the correct dosage of a medication, then page you to tell you that the dosage is wrong. On a related note, answer your pager as soon as you can. I know it took me a week to get used to dropping everything to answer my pages.
#3 – Own your patients. I think the best advice I was ever given as a medical student was to own my patients. This means you should know your patients. Know their history and their plan. Be thorough and complete. Update your patients and educate them. You are the primary doctor now. This may be daunting, but you are never alone. There is always a senior and an attending.
#4 – Know your limitations. If you don’t know something (i.e lab value, plan, etc.), admit that you don’t know. It’s okay if you don’t know the answer; we are all here to learn. Do not, I repeat, do not ever lie. Once you say something incorrect, your seniors, colleagues, attending and patients will find it hard to trust you again. I’ve found the best answer to give when you’re stumped is, “I don’t know the answer to that, but I will find out for you.” It’s gold. Use it, and follow through with it. Do what you say, and say what you do. Communication is key. Again, back to #1, ask someone who would know. Ask for help when you’re feeling overwhelmed. Ask your senior or a colleague for help. They are all there to provide the best patient care as a team. Finally, be a team player and help your colleagues out.
#5 – Take care of yourself. I know we hear it all the time, but seriously, sit when you can sit, eat when you can eat and sleep when you can sleep. In the first two weeks of residency, I lost seven pounds because I wasn’t eating. I remember falling asleep shaking because I was hypoglycemic. You cannot take care of patients if you are a patient yourself. Also, use the bathroom. I know it sounds ridiculous, but I’ve met residents who have had UTIs because they didn’t have time to use the bathroom. And yes, you will get paged in the bathroom!
#6 – Read up on your patients. I know it’s hard to pick up an article or a book at the end of a 12+ hour day, but try to read a little every day. You can try reading articles, but I found that, at an intern level, it’s best to get a foundation by reading textbooks. Not Harrison’s or Nelsons textbooks, but Pediatrics – Just the Facts or Ferri’s Clinical Advisor for Medicine. Something quick and straight to the point. Once you have the foundation down, you can add to your knowledge with articles, guidelines, etc. The details come later. Get the basics down first!
#7 – Residency is work. You are finally getting paid to work, so don’t complain. If you have to vent, be careful to whom you vent because rumors spread fast and the last thing you want is to build animosity within your program. You will be working with each other for the next three to five years, so be nice to each other. Be respectful. Be a team player. Everyone had to be smart at some level to get where they are, so listen to each other. Don’t be condescending. Apologize if you’ve slighted someone. If you do have a conflict with another resident or nurse, speak with them privately. If that’s not possible, speak with your chief resident or director. They are there to help resolve conflicts. The last places to engage in an argument are in the patient’s chart, in front of patients, or in your evaluation of the program. If you have allegiance to your program, the last thing you want to do is jeopardize your program with a bad evaluation. Let your chief or director know you have a problem and give them a fair chance to rectify the situation before you put it in writing.
#8 – Smile. Yes, smile. Smiling goes a long way. Be kind to nurses, LPNs, social workers, respiratory therapists, pharmacists, secretaries, case managers, environmental services personnel — everyone you meet. Introduce yourself. Remember, you’re the new kid on the block. If you’re respectful, considerate and friendly to everyone, it will only benefit you. Those around you will be more inclined to help if they know who you are. There have been countless times when nurses have gone out of their way to place IVs or check labs when I was swamped. Respiratory therapists have called to update me on my asthmatic kids and pharmacists have corrected my orders. It is just nice to know that you are not alone.
Is It Really Worth its Weight in Gold?
By: Jason B. Lester,MD, MBA
As an emergency medicine resident with an interest in business, I have always wondered if the drugs I prescribe really live up to their worth. In medical school, we learn which drugs are used to treat specific conditions, and which may be more efficacious. However, in treating patients, I just want what is best for them. In real life, cost is an issue. Recently, I asked myself why I was giving one medication over another. Both seemed to help the condition I was treating. When I asked my attending for his opinion, issues regarding patient care, budgets, and doing what is right surfaced. In the end, cost came out as a large influence on decision-making.
One of the most precious and stable commodities in the world is gold. People such as Spanish explorer Hernando Cortez have traveled great distances in search of it. Many have lost their lives for a chance to own a small piece of it. It is the theoretical basis for our modern economy. We watch prices in the newspaper and always seem astonished by the cost of gold. I wondered, “How does it compare, weight-to-weight, to the drugs I prescribe?”
Let’s take a look. On November 1, 2006, the price of gold per troy ounce was $619.30. To compare apples to apples, we have to convert the troy ounce to milligrams. One troy ounce is 31.1034768 grams. After the conversion, one milligram of gold costs roughly two cents. In light of this, a milligram of the “most sought-after” commodity does not sound like much.
Now, let’s look at how much we are paying for drugs that we sometimes prescribe, without a second thought, to our patients. With varying costs due to contracts, sales, and other market forces, I went to the Internet to find prices for some common drugs. For one subset, I chose drugs that treat nausea and vomiting; the other subset consisted of “luxury drugs” for hair loss and erectile dysfunction. The search date was November 1, 2006, the same date I searched the price of gold.
Three drugs which can be used for nausea and vomiting are: Phenergan, Reglan, and Zofran. Clinical practice and patient response may vary with these drugs. For our purposes, I will assume that one dose of the drug will provide symptom relief. According to the website Drugstore.com, the going rate for a 25 mg pill of Phenergan is $0.599, or about $0.0239 a milligram; just slightly over 2 cents (remember, gold per milligram is slightly under 2 cents). Reglan, offered in 5 mg pills, is about 15 cents per milligram. Lastly, Zofran, offered in 4 mg pills, is $23.20, costing $5.80 per milligram, or 290 times the value of gold.
For patients using luxury drugs, the treatment options vary, and the cost is surprisingly lower than one might expect. For help with erectile dysfunction, Cialis is available for $12.10 per 5 mg pill, or $2.41 per milligram. Its rival, Viagra, comes in a 25 mg pill, costing $9.99, or $0.40 per milligram. For hair-loss sufferers, finasteride, which is sold under the name Propecia, comes in 1 mg pills for about $1.99 each. Interestingly, finasteride is also used in a higher dose of 5 mg, to treat benign prostatic hyperplasia (BPH), and the cost per 5 mg pill is $3.10, or only $0.62 per milligram. Makes me want to cut up the 5 mg pill for those savings, or better yet, buy gold, because my hair will probably fall out eventually!
In then end, I was looking for some sort of perspective, which I believe I have found. Imagine Cortez sailing for the New World, not to find El Dorado but “El Zofrano.” We treat gold like gold. We keep it in safes and in banks, heavily guarded. However, we prescribe medications at times without even looking at how they compare to other things in life, business, and society. Perhaps we should protect these medications more carefully, since many can be worth their weight in gold, or maybe even much more.