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Part 1. Approach to the Patient
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The transition of information from the textbook or journal article to the clinical situation is perhaps the most challenging in medicine. Retention of information is difficult; organization of the facts and recall of myriad data to apply to the patient are crucial. This text aids in the process. The first step is gathering information, otherwise known as establishing the database. This consists of taking the history (asking questions), performing the physical examination, and obtaining selective laboratory and/or imaging tests.
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The history is the single most important method of establishing a diagnosis. Depending on the age of the child, the information may be gathered solely from the parent, from both the parent and the child, or solely from the adolescent. The student should remember not to be misled by the diagnosis of another physician or by a family member. A statement such as “Johnnie has pneumonia and needs antibiotics” may or may not be correct; an astute clinician will keep an open mind and consider other possibilities, such as upper respiratory tract infection, aspirated foreign body, reactive airway disease, or even cystic fibrosis. The art of seeking the information in a nonjudgmental, sensitive, and thorough method cannot be overemphasized.
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Basic information:
Age, gender, and ethnicity are important because some childhood illnesses occur with increased regularity at various ages, with higher frequency in one gender or more commonly in one ethnic group. For instance, anorexia nervosa is more common in white adolescent females, whereas complications of sickle cell anemia are more common in African American children of both genders.
Chief complaint: This is usually the response that the patient or the patient's family member gives to the question: “Why are you seeing the doctor today?”
History of present illness: The onset, duration, and intensity of the primary complaint, as well as associated symptoms, exacerbating and relieving factors, and previous attempts at therapy should be determined. For children, especially adolescents, a hidden agenda must be considered; it is not uncommon for the adolescent to actually have questions about sexuality when the stated reason for the office visit is totally unrelated. Both positive findings (the stool was loose, voluminous, and foul smelling) and negative findings (without blood or mucus) are appropriate.
Past history:
Pregnancy and delivery: The age of the mother, the number of pregnancies, the route of delivery, and the gestational age of the infant often can provide clues as to the etiology of pediatric conditions. For instance, a large, full-term infant born by cesarean delivery who then develops an increased respiratory rate and streakiness on chest radiograph is more likely to have transient tachypnea of the newborn than is an infant born vaginally at 28-week gestation with similar symptoms where a diagnosis of surfactant deficiency is the more likely cause of respiratory symptoms. Similarly, a history of drug use (including over-the-counter, prescription, and illicit drugs) or infections during pregnancy should be obtained.
Neonatal history: Any problems identified in the neonatal period, such as severe jaundice, infections, feeding difficulties, and prolonged hospitalization, should be reviewed, especially for the younger pediatric patients in whom residua of these problems may remain.
Surgical history: When, where, and for what reason the surgery was performed should be explored. Complications should be noted.
Medical history: Whereas minor illnesses (such as occasional upper respiratory infections) can be reviewed quickly, more serious illnesses (such as diabetes mellitus) should be investigated fully. The age at diagnosis, treatments prescribed, and response to therapies can be reviewed. The number and nature of hospitalizations and complications are often important. For instance, a diabetic patient with frequent hospitalizations for ketoacidosis may indicate a lack of education of the family or underlying psychosocial issues complicating therapy. A child with a history of frequent, serious accidents should alert the physician of possible child abuse.
Developmental history: For preschool children, a few questions about language and fine motor, gross motor, and psychosocial skills will provide good clues about development. For school-aged children, school performance (grades) and areas of strength and weaknesses are helpful.
Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medications.
Immunizations: Dates for primary and booster series of immunizations should be recorded, preferably by reviewing the immunization cards or accessing the state's immunization registry. If the child is in school, a presumption about state laws regarding immunization completion can be made while the immunization card is being retrieved.
Medications: List the names of current medications, dosages, routes of administration and frequency, and durations of use. Prescription, over-the-counter, and herbal remedies are relevant.
Sexual history of adolescents: Details of an adolescent's sexual habits, contraceptive use, pregnancies, and sexually transmitted diseases should be determined.
CLINICAL PEARL
Family history: Because many conditions are inherited, the ages and health of siblings, parents, grandparents, and other family members can provide important diagnostic clues. For instance, an obese child with a family history of adult-onset diabetes is at high risk for developing diabetes; early intervention is warranted.
Social history: Living arrangements, economic situations, type of insurance, and religious affiliations may provide important clues to a puzzling diagnostic case or suggest important information about the acceptability of therapeutic options.
Review of systems: A few questions about each of the major body systems allows the practitioner to ensure that no problems are overlooked and to obtain crucial history about related and unrelated medical conditions.
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General appearance: Well versus poorly nourished; evidence of toxemia, including lethargy (defined as poor or absent eye contact and refusal to interact with environment), signs of poor perfusion, hypo- or hyperventilation, and cyanosis; or stigmata of syndromes (such as Down or Turner).
Skin: In smaller children, checking the color of the skin for evidence of pallor, plethora, jaundice, or cyanosis is important. Abnormalities such as capillary hemangiomas (eg, “stork bites” in a newborn), café-au-lait spots, pigmented nevi (eg, “Mongolian spots”), erythema toxicum, or pustular melanosis can be identified. In older children, macules, papules, vesicles, pustules, wheals, and petechiae or purpura should be described, and evidence of excoriation, crust formation, desquamation, hyperpigmentation, ulceration, scar formation, or atrophy should be identified.
Vital signs: Temperature, blood pressure (generally begin routine measurement after 3 years), heart rate, respiratory rate, height, weight, and head circumference (generally measured until age 3 years). Measurements are plotted and compared to normals for age.
Head, eyes, ears, nose, mouth and throat:
Head: For the neonate, the size of fontanelles and presence of overriding sutures, caput succedaneum (superficial edema or hematoma that crosses suture lines, usually located over crown), or cephalohematoma (hematoma that does not cross suture lines) should be noted. For the older child, the size and shape of the head as well as abnormalities such as swellings, depressions, or abnormal hair quality or distribution may be identified.
Eyes: For infants, abnormalities in the size, shape, and position of the orbits, the color of the sclera (blue sclera, for instance, may indicate osteogenesis imperfecta), conjunctival hemorrhages, or the presence of iris defects (such as coloboma) may be found. The visual acuity of older children should be determined.
Ears: For all children, abnormalities in the size, shape, and position of the ears can provide important diagnostic clues. Whereas tympanic membranes are difficult to assess in newborns, their integrity should be assessed in older children. For all children, the quality and character of discharge from the ear canal should be documented.
Nose: The size, shape, and position of the nose (in relation to the face and mouth) can provide diagnostic clues for various syndromes, such as a small nose in Down syndrome. Patency of the nostrils, especially in neonates who are obligate nose breathers, is imperative. Abnormalities of the nasal bridge or septum, integrity of the mucosa, and the presence of foreign bodies should be noted. A butterfly rash around the nose can be associated with systemic lupus erythematosus (SLE), and a transverse crease across the anterior portion of the nose is seen with allergic rhinitis.
Mouth and throat: The size, shape, and position of the mouth and lips in relation to other facial structures should be evaluated. In infants, common findings of the mouth include disruption of the palate (cleft palate syndrome), Epstein pearls (a tiny white papule in the center of the palate), and short frenulum (“tongue-tied”). For all children, the size, shape, and position of the tongue and uvula must be considered. The number and quality of teeth for age should be assessed, and the buccal mucosa and pharynx should be examined for color, rashes, exudate, size of tonsils, and symmetry.
Neck: The neck in infants usually is short and sometimes hard to evaluate. Nonetheless, the size, shape, and preferred position of the neck can be evaluated for all children. The range of motion can be evaluated by gentle movement. Symmetry of the muscles, thyroid gland, veins, and arteries is important. An abnormal mass, such as a thyroglossal duct cyst (midline above the level of the thyroid) or brachial cleft cyst (along the sternomastoid muscle), or unusual findings, such as webbing in Turner syndrome, can be identified.
Chest: General examination of the chest should include an evaluation of the size and shape of the structures along with identification of obvious abnormalities (such as supernumerary nipples) or movement with respirations. Respiratory rate varies according to age and ranges from 40 to 60 breaths/min in the neonate to 12 to 14 breaths/min in the toddler. The degree of respiratory distress can be stratified, with increasing distress noted when the child moves from subcostal to intercostal to supraclavicular to suprasternal retractions. Palpation of the chest should confirm the integrity of the ribs and clavicles, and any swelling or tenderness in the joints. Percussion in older children may reveal abnormalities, especially if asymmetry is noted. The chest should be auscultated for air movement, vocal resonance, rales, rhonchi, wheezes, and rubs. In adolescent girls, symmetry of breast development and presence of masses or nipple discharge should be evaluated.
Cardiovascular: The precardium should be inspected for abnormal movements. The chest should be palpated for the location and quality of the cardiac impulse, and to determine if a thrill is present. The presence and quality of the first and second heart sounds, including splitting with respirations, should be noted. Murmurs, clicks, rubs, and abnormalities in the heart rate (which vary by age) or rhythm should be identified. The peripheral perfusion, pulses, and color should be assessed.
Abdominal examination: The abdomen should be inspected to determine whether it is flat or protuberant, if masses or lesions such as striae are obvious, or if pulsations are present. In older children, the abdomen usually is flat, but in the neonate a very flat abdomen in conjunction with respiratory distress may indicate diaphragmatic hernia. The umbilicus, especially for neonates, should be evaluated for defects, drainage, or masses; a small umbilical hernia often is present and is normal. In the newborn, one umbilical vein and two umbilical arteries are normal. In the neonate, palpation of the abdomen may reveal a liver edge about 2 cm below the coastal margin, a spleen tip, and using deep pressure, kidneys. In older children, these structures are not usually palpable except in pathology. Depending on the history, other masses must be viewed with suspicion for a variety of conditions. Bowel sounds are usually heard throughout the abdomen except in pathology. In adolescent girls, the lower abdomen should be palpated for uterine enlargement (pregnancy).
Genitalia: Examination of the male for the size and shape of the penis, testicles, and scrotum is important. The position of the urethral opening should be assessed. In newborn girls, the labia majora usually is large and completely encloses the labia minora; the genitalia usually is highly pigmented and swollen with an especially prominent clitoris. A white discharge is usually present in the first days of life, and occasionally a blood-tinged fluid is also seen. In toddlers, examination of the genitalia can be challenging. Placing the toddler in a frog-leg position while the toddler sits in the parent's lap (or on the examination table) often allows successful viewing of external genitalia. In older girls, the knee-chest position affords an excellent view of the external genitalia. In girls outside the newborn period, the labia minora are smaller compared to the remainder of the external genitalia, and the vaginal mucosa is red and appears thin. The hymen, which is just inside the introitus, should be inspected. Abnormalities of the hymen, such as imperforation or tags, vaginal discharge, foreign bodies, and labial adhesions, may be noted. A speculum examination should be performed for sexually active adolescent girls. Tanner staging for pubertal development should be done for both boys and girls. Inguinal hernias should be identified; normalcy of anus should be confirmed.
Extremities: For all children, the size, shape, and symmetry of the extremities should be considered; muscle strength should be evaluated. Joints may be investigated for range of motion, warmth, tenderness, and redness. Normalcy of gait for age should be reviewed. For infants, recognition of dislocated hips is of critical importance, because lifelong growth abnormalities may result. For adolescents, identification of significant scoliosis is important to prevent the debilitating complications of that condition. Athletes require evaluation of the integrity of their joints, especially those joints that will be used in sporting activities.
Neurologic: Neurologic evaluation of the older child is similar to that in adults. Consciousness level and orientation are determined as a starting point. The cranial nerves should be assessed. The motor system should be evaluated (including strength, tone, coordination, and involuntary movements). Superficial and deep sensory systems, and deep tendon reflexes should be reviewed. In younger infants, a variety of normal primitive reflexes (Moro, parachute, suck, grasp) can be found, but ensuring that these reflexes have extinguished by the appropriate age is equally important.
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The American Academy of Pediatrics recommends a few laboratory screening tests be accomplished for pediatric patients. These tests vary according to the child's age and risk factors.
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Newborn metabolic screening is done in all states, usually after 24 hours of age, but the exact tests performed vary by state. Conditions commonly screened for include hypothyroidism, phenylketonuria, galactosemia, hemoglobin type, and adrenal hyperplasia. Other conditions that may be assessed include maple syrup urine disease, homocystinuria, biotinidase deficiency, cystic fibrosis, tyrosinemia, and toxoplasmosis. Some states require a second newborn screen be performed after 7 days of age.
Measurement of oxygen saturation in all newborn infants is accomplished to assess for critical congenital heart defects.
Hemoglobin or hematocrit levels are recommended for high-risk infants (especially premature infants and those with low birth weight), at about 12 months of age, and as needed yearly if the risk of blood loss (such as menstruating adolescents) is high.
Lead screening is done, especially in high-risk areas, at 9 to 12 months of age and again at 2 years of age.
Cholesterol screening is performed in high-risk patients (those with positive family histories) older than 24 months.
Sexually transmitted disease screening is performed yearly on all sexually active patients.
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Other specialized testing is accomplished depending on the child's age, risk factors, chief complaint, and conditions included in the differential diagnosis.
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Plain radiographs offer the advantage of inexpensive testing that reveals global views of the anatomy. Unfortunately, fine organ detail sometimes is not revealed which requires further radiographic study. Bone films for fracture, chest films for pneumonia, and abdomen films for ileus are common uses of this modality.
Ultrasonography is a fairly inexpensive modality that requires little or no sedation and has no radiation risks. It offers good organ and anatomic detail, but it can be operator dependent. Not all organs are accessible to sonography. Common examinations include the head for intraventricular hemorrhage (IVH) in the premature infant, the abdomen for conditions such as pyloric stenosis or appendicitis, and the kidneys for abnormal structure.
Computerized tomography (CT) provides good organ and anatomic detail and is quick, but it is fairly expensive, may require contrast, and does involve radiation. Some children require sedation to complete the procedure. This test is often performed on the abdomen or head in trauma victims.
Magnetic resonance imaging (MRI) is expensive but does not involve radiation. Because it is a slow procedure, sedation is often needed for younger children, and contrast is sometimes required. It allows for superb tissue contrast in multiple planes, and excellent anatomic and functional imaging. It is frequently used to provide detail of the brain in patients with seizures or developmental delay, or to provide tissue detail on a mass located virtually anywhere in the body.
Nuclear scan is moderately expensive and invasive. It provides functional information (usually organ specific) but poor anatomic detail. Radiation is involved. Common uses include bone scans for infection and renal scans for function.
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Part 2. Approach to Clinical Problem Solving
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There are generally four steps to the systematic solving of clinical problems:
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Make the diagnosis.
Assess the severity of the disease.
Render a treatment based on the stage of the disease.
Follow the response to the treatment.
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This is achieved with careful sifting of the database, analysis based on the risk factors present, and development of a list of possibilities (the differential diagnosis). The process includes knowing which pieces of information are more meaningful and which can be discarded. Experience and knowledge from reading help to guide the physician to key in on the most important concerns. A good clinician also knows how to ask the same question in several different ways and using different terminology, because patients at times will deny having been treated for asthma but will answer affirmatively to being hospitalized for wheezing. A diagnosis can be reached by systematically reviewing each possible cause and reading about each disease. The patient's presentation is then matched up against each of these possibilities and either placed higher up on the list as a potential etiology or lower down because of the disease frequency, the patient's presentation, or other clues. A patient's risk factors may influence the probability of a diagnosis. Usually a long list of possible diagnoses can be pared down to two or three top suspicions, based on key laboratory or imaging tests. For example, an adolescent presenting with a fever as the chief complaint can have an extensive differential diagnosis reduced to far fewer possibilities when the history reveals an uncle in the home with cough that contains blood, weight loss, and night sweats, and the physical examination shows an increased respiratory rate, lymphadenopathy, and right lower lobe lung crackles. In this case, the patient likely has tuberculosis.
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Assessing the Severity of the Disease
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The next step is to characterize the severity of the disease process. In asthma, this is done formally based on guidelines promulgated by the National Heart, Lung, and Blood Institute (NHLBI). Asthma categories range from mild intermittent (least severe) to severe persistent (most severe). For some conditions, such as syphilis, the staging depends on the length of time and follows along the natural history of the infection (ie, primary, secondary, or tertiary syphilis).
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Rendering Treatment Based on the Stage of the Disease
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Many illnesses are stratified according to severity because prognosis and treatment vary based on the severity. If neither the prognosis nor the treatment was affected by the stage of the disease process, it would not make much sense to subcategorize something as mild or severe. As an example, mild intermittent asthma poses less danger than does severe persistent asthma (particularly if the patient has been intubated for asthma in the past). Accordingly, with mild intermittent asthma, the management would be intermittent short-acting β-agonist therapy while watching for any worsening of the disease into more serious categories (more severe disease). In contrast, a patient with severe persistent asthma would generally require short-acting β-agonist medications as well as long-acting β-agonists, inhaled steroids, and potentially oral steroids.
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Group A β-hemolytic streptococcal pharyngeal infection (“strep throat”) is associated with complications including poststreptococcal glomerulonephritis and rheumatic fever. The presence of group A β-hemolytic streptococcus confers an increased risk of problems, but neither the prognosis nor the treatment is affected by “more” group A β-hemolytic streptococcus or “less” group A β-hemolytic streptococcus. Hence, the student should approach new disease by learning the mechanism, clinical presentation, how it is staged, and how the treatment varies based on stage.
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Following the Response to Treatment
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The final step in the approach to disease is to follow the patient's response to the therapy. Whatever the “measure” of response, it should be recorded and monitored. Some responses are clinical, such as a change in the patient's pain level or temperature, or results of pulmonary examination. Obviously the student must work on being more skilled in eliciting the data in an unbiased and standardized manner. Other patients may be followed by imaging, such as CT scan of a retroperitoneal (RP) node size in a patient receiving chemotherapy for neuroblastoma, or a marker such as the platelet count in a patient recovering from Kawasaki syndrome. For syphilis, it may be the nonspecific treponemal antibody test rapid plasma reagin (RPR) titer every month. The student must know what to do if the measured marker does not respond according to the expected. Is the next step to treat further, or to repeat the metastatic workup, or to follow up with another more specific test?
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Part 3. Approach to Reading
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The student must approach reading differently than the classic “systematic” review of a particular disease entity. Patients rarely arrive to their health care provider with a clear diagnosis; hence, the student must become skilled in applying the textbook information to the clinical setting. Everyone retains more when the reading is performed with a purpose. Experience teaches that with reading; there are several crucial questions to consider thinking clinically. They are as follows:
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What is the most likely diagnosis?
What should be your next step?
What is the most likely mechanism for this process?
What are the risk factors for this condition?
What are the complications associated with this disease?
What is the best therapy?
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What is the Most Likely Diagnosis?
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Establishing the diagnosis was discussed in the previous part. This is a difficult task to give to the medical student; however, it is the basic problem that will confront clinicians for the rest of their careers. One way of attacking this problem is to develop standard “approaches” to common clinical problems. It is helpful to memorize the most common causes of various presentations, such as “the most common cause of mild respiratory distress in a term infant born by cesarean section is retained amniotic fluid (transient tachypnea of the newborn).”
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The clinical scenario would entail something such as the following:
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“A 3-hour-old infant is noted to have a mildly increased respiratory rate and slight subcostal retractions. The infant is term, large for gestation age, and was born by repeat cesarean section. The pregnancy was uncomplicated. What is the most likely diagnosis?”
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With no other information to go on, the student would note that this baby has respiratory distress. Using the “most common cause” information, the student would guess transient tachypnea of the newborn. If, instead, the gestational age “term” is changed to “preterm at 30 weeks' gestation,” a phrase can be added, such as the following:
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“The mother did not receive prophylactic steroids prior to birth.”
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Now, the student would use the “most common cause of respiratory distress in a preterm child whose mother did not receive prenatal steroids” is surfactant deficiency (respiratory distress syndrome).
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What should be your Next Step?
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This question in many ways is even more difficult than the most likely diagnosis, because insufficient information may be available to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that the diagnosis is clear, but the subsequent step is the staging of the disease. Finally, the next step may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:
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Make diagnosis → Stage disease → Treatment based on the stage → Follow response
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In particular, the student is accustomed to regurgitating the same information that someone has written about a particular disease but is not skilled at giving the next step. This talent is optimally learned at the bedside, in a supportive environment, with freedom to take educated guesses, and with constructive feedback. The student in assessing a child in the hospital should go through the following thinking process:
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Based on the information I have, I believe that Cedric Johnson (a 3-month-old child with a positive respiratory syncytial virus nasal washing) has bronchiolitis.
I don't believe that this is severe disease (such as significant oxygen requirement, severe retractions, or carbon dioxide retention on blood gas analysis). A chest radiograph shows no lobar consolidation (I believe this is important because a lobar consolidation would suggest a bacterial etiology).
Therefore, the treatment is supportive care with supplemental oxygen and intravenous fluids as needed.
I want to follow the treatment by assessing Cedric's respiratory status (I will follow the oxygen saturation and degree of retractions), his temperature, and his ability to maintain his hydration orally without intravenous fluids. Also, if in the next few days Cedric does not get better or if he worsens, I think he will need a repeat chest radiograph to assess whether he has an evolving bacterial pneumonia.
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In a similar patient, when the clinical presentation is not so clear, perhaps the best “next step” may be diagnostic in nature such as blood cultures to determine if bacteremia is present. This information is sometimes tested by the dictum, “the gold standard for the diagnosis and treatment of a bacterial infection is a culture.”
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Sometimes the next step is therapeutic.
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What is the Most Likely Mechanism for this Process?
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This question goes further than requiring the student to make the diagnosis; it also requires the student to understand the underlying mechanism for the process. For example, a clinical scenario may describe a 5-year-old child with Henoch-Schönlein purpura (HSP) who develops abdominal pain and heme-positive stools a week after diagnosis. The student first must diagnose the heme-positive stools associated with HSP, which occur in approximately 50% of patients. Then, the student must understand that the edema and damage to the vasculature of the gastrointestinal (GI) tract can cause bleeding along with colicky abdominal pain, sometimes progressing to intussusception. The mechanism of the pain and bleeding is, therefore, vasculitis causing enlarged mesenteric lymph nodes, bowel edema, and hemorrhage into the bowel. Answers that a student may speculate, but would not be as likely, include appendicitis, bacterial gastroenteritis, or volvulus.
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The student is advised to learn the mechanisms for each disease process and not merely to memorize a constellation of symptoms. In other words, rather than trying to commit to memory the classic presentation of HSP (typical rash, abdominal pain, and arthritis), the student should also understand that vasculitis of the small vessels is the culprit. The vasculitis causes edema, mainly in the dependent areas, that precedes the palpable purpura. This vasculitis is responsible not only for edema in the joints (mainly in dependent areas such as the knees and ankles) causing the arthritis found in approximately two-thirds of patients, but also damage to the vasculature of the GI tract leading to the intermittent, colicky abdominal pain that can manifest as heme-positive stools or even intussusception.
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What are the Risk Factors for this Condition?
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Understanding the risk factors helps to establish the diagnosis and interpret test results. For example, understanding the risk factor analysis may help to manage a 1-year-old child with anemia found on routine screening. If the child had no risk factors for lead poisoning or thalassemia, the practitioner may choose to treat with supplemental iron because the likelihood for more serious pathology is low. On the other hand, if the same 1-year-old child was a recent immigrant from an endemic area, lived in a older home with peeling paint, had a father who worked at a battery smelting plant, and ate meals from unglazed pottery, a practitioner should presumptively diagnose lead poisoning until proven otherwise. The physician may want to obtain a serum lead level and a complete blood count with differential (looking for basophilic stippling and microcytosis), and thoroughly evaluate the child for developmental delay. Thus, the number of risk factors helps to categorize the likelihood of a disease process.
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What are the Complications Associated with this Disease?
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A clinician must understand the complications of a disease so that the patient can be monitored. Sometimes, the student will have to make the diagnosis from clinical clues and then apply his or her knowledge of the sequelae of the pathologic process. For example, a child diagnosed with high fever, rash, lymphadenopathy, and oral and conjunctival changes is diagnosed with Kawasaki syndrome. Complications of this condition include arthritis, vasculitis of the medium-sized arteries, hydrops of the gallbladder, urethritis, and aseptic meningitis. Understanding the types of complications helps the clinician to assess the patient. For example, one life-threatening complication of Kawasaki syndrome is coronary artery aneurysm and thrombosis. The clinical presentation in the subacute phase is desquamation, thrombocytosis, and the development of coronary aneurysms with a high risk of sudden death. The appropriate therapy is intravenous immunoglobulin in the acute phase and high-dose aspirin as soon as possible after the diagnosis is made. Nonrecognition of the risk of coronary artery aneurysm and appropriate therapy for thrombosis can lead to the patient's death. Students apply this information when they see on rounds a patient with Kawasaki syndrome and monitor for new murmurs, thrombocytosis, myocarditis, and development of coronary artery aneurysms. The clinician communicates to the team to watch the patient for any of these signs or symptoms so that appropriate therapy can be considered.
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What is the Best Therapy?
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This is perhaps the most difficult question, not only because the clinician needs to reach the correct diagnosis, and assess the severity of the condition, but also because he or she must weigh the situation to reach the appropriate intervention. The student does not necessarily need to memorize exact dosages, but the medication, the route of delivery, and possible complications are important. It is important for the student to verbalize the diagnosis and the rationale for the therapy. A common error is for the student to “jump to a treatment,” almost like a random guess, and therefore be given a “right or wrong” feedback. In fact, the student's guess may be correct but for the wrong reason; conversely, the answer may be a very reasonable one, with only one small error in thinking. It is crucial instead to give the steps so that feedback can be given for each step.
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For example, what is the best therapy for a 15-year-old sexually active girl with severe, cystic acne? The incorrect manner of response is for the clinician to blurt out “Accutane.” Rather, the student should reason it as follows:
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“Severe, cystic acne can be treated with a variety of modalities. Side effects of the medications must be considered in a sexually active teenager who is statistically at high risk for pregnancy. Accutane causes severe birth defects and is absolutely contraindicated in pregnancy. Therefore, the best treatment for this adolescent may be a combination of oral antibiotics and topical medications that present a much lower chance of devastating side effects.”