What Causes Sweaty Babies?

Patient Presentation
A 9 month-old male came to clinic for his health supervision visit.
His parents had no complaints but when discussing sleeping they asked why his head always seemed sweaty at night.
Originally they thought that he was overdressed, but even with different temperatures or clothing his head always sweats at night.
They report that he occasionally does this during naps also, but not when awake. He is afebrile and the rest of his body does not seem to sweat during these episodes. He others apepars to sweat normally when exposed to excessive heat or if febrile.
His past medical history, family history and review of systems are all negative.
The pertinent physical exam shows a developmentally appropriate male with growth parameters in the 75-90% and normal growth curves.
His physical examination was unremarkable.
The diagnosis of idiopathic hyperhidrosis of the scalp was made. The pediatrician told the parents that this is fairly common but the cause is unknown.
As the patient had an otherwise normal history and physical examination the pediatrician recommended monitoring and to call if the sweating occurs at other times, changes or new symptoms occur.
The patient’s clinical course over the next 5 years showed almost nightly hyperhidrosis of the scalp but the child continued to grow and develop normally.

Discussion
Sweating is made by the eccrine glands and is a normal physiologic response that helps to maintain body temperature.

Hyperhidrosis is sweating beyond what is needed to maintain normal temperature regulation.
It can be primary or secondary, and generalized, regional or focal, regional.
Some studies report a prevalence of 1-2.8%, but this may be underreported.
Hyperhidrosis can be not only socially a problem, but may not allow people to have careers in areas that contact paper, metal or electrical components.
Hyperhidrosis can also damage clothing, shoes and furniture too.

Sweating around the head particularly during sleep is a common finding especially in children. The cause is not understood.
Sweating of the palms and soles is also common particularly if in a stressful situation or if in an enclosed environment (i.e. shoes, coat pockets, etc.).
Axillary sweating is often caused by anxiety and thermal stimuli.

Treatment for hyperhidrosis includes many options depending on the location, potential cause, and severity.
Topical treatments include antiperspirants, tannic acid, formalin, glutaraldyde and anticholinergics.
System treatment includes anticholinergics, botulinum toxin, calcium-channel blockers, clonidine, and non-steroidal antiinflammatory drugs.
Surgical treatment includes excision of axillary sweat glands, liposuction, and sympathectomy.
Electrical treatment includes iontophoresis.

Learning Point

The causes of hyperhidrosis include:

  • Endocrine
    • Acromegaly
    • Diabetes mellitus
    • Gout
    • Hyperpituitarism
    • Hypoglycemia
    • Menopause – secondary
    • Thyrotoxicosis
  • Environment (most common)- heat illnesses, elevated humidity, exercise
  • Dermatologic
    • Eccrine nevus
  • Drugs
    • Alcohol
    • Amitriptyline
    • Amphetamine
    • Antihistamine
    • Ephedrine
    • Haloperidol
    • Methylphenidate
    • Propanolol
    • Phenothiazine
    • Physostigmine
    • Pilocarpine
  • Drug withdrawal
  • Fever
    • Infections, acute and chronic
  • Genetic
    • Episodic spontaneous hypothermia with hyperhidrosis
    • Familial dysautononia (i.e. Riley-Day syndrome)
  • Idiopathic
    • Primary or essential hyperhidrosis
  • Oncologic (may have fever also)
    • Carcinoid tumor
    • Neoplasia, general
    • Neuroblastoma
    • Pheochromocytoma
  • Neurologic
    • Generalized
      • Anxiety
      • Fainting
      • Gustatory or Olfactory
        • Citric acid
        • Coffee
        • Chocolate
        • Peanut butter
        • Spicy foods
      • Pain
      • Shock
    • Focal or regional
      • Peripheral nerve damage
        • Auriculotemporal syndrome (i.e. Frey’s Syndrome, nerve damage near parotid gland with focal sweating in area)
      • Ross syndrome ( e.g. sweating associated with areflexia and tonic pupil)
      • Spinal cord lesion
      • Stroke

Questions for Further Discussion
1. How does iontophoresis work to decrease hyperhidrosis?
2. When should hyperhidrosis prompt an evaluation for a possible neoplasm?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sweat

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:45-56.

Greenberg RA, Rittichier KK.
Pediatric nonenvironmental hypothermia presenting to the emergency department:
Episodic spontaneous hypothermia with hyperhidrosis. Pediatr Emerg Care. 2003 Feb;19(1):32-4.

Stolman LP.
Treatment of hyperhidrosis.
Dermatol Clin. 1998 Oct;16(4):863-9.

Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, Ahn S, Stolman LP; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis.
Recognition, diagnosis, and treatment of primary focal hyperhidrosis.
J Am Acad Dermatol. 2004 Aug;51(2):274-86.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge

    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement

    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    July 28, 2008

  • What Causes Congenital Cholesteatomas?

    Patient Presentation
    A 3-year-old female came to clinic with a report from the local preschool that she had failed her screening hearing test in her right ear.
    Mother had not noted any problems hearing and said that she had 2 ear infections previously with the last one being more than 1 year ago.
    The patient was otherwise well except for an upper respiratory infection about 1 month ago.
    The family history was negative for any hearing problems and kidney problems.
    The review of systems was negative.
    The pertinent physical exam showed a happy, interactive female with no obvious gross hearing deficits during examination.
    Growth parameters were 75-90%. HEENT showed a small amount of fluid behind the tympanic membrane with no erythema and normal mobility bilaterally.
    The posterior 1/2 of the right tympanic membrane was obscured by cerumen.
    The physician diagnosed bilateral middle ear effusion. He ordered an audiogram to be done in 2 weeks to allow time for the effusion to clear.
    He also recommended over-the-counter cerumen drops to aid visualization at her follow-up appointment in 2 weeks.
    Two weeks later, the effusions had cleared but he thought that there was a possible mass behind the right tympanic membrane posteriorly.
    The audiogram also showed a persistent conductive hearing loss on the right.
    The patient was referred to an otolaryngologist who also agreed that there was possibly a mass behind the tympanic membrane.
    The radiologic evaluation by computed tomography of the head revealed a 2×3 cm mass inferior to the ossicles without erosion into the skull bones, clinically consistent with a diagnosis of a congenital cholesteatoma.
    The patient’s clinical course had her taken to the operating room for removal of the cholesteatoma. Unfortunately, it had eroded into the incus and head of the malleus but the other ossicles were salvaged.
    Ossicular reconstruction was planned in the future. A 2-week post-operative audiogram showed mild-moderate conductive hearing loss at some frequencies but improvement to normal at higher frequencies.
    A hearing aid was also prescribed to increase amplification.


    Figure 65 – Axial computed tomography images obtained
    without contrast of the right and left temporal bones at the same
    level demonstrate a 2 mm x 3 mm soft tissue lesion within the right
    middle ear cavity, inferior to the ossicles. The ossicular chain was
    intact. The lesion was felt to be compatible in appearance with a
    cholesteatoma.

    Discussion
    Cholesteatomas are an epithelial-lined sac that contains squamous debris that progressively expands, potentially causing morbidity and even mortality.
    They most often are acquired but can be congenital.
    Morbidity includes secondary infection of the lesion and/or middle ear structures, destruction of the ossicles with potentially permanent hearing loss, destruction of the skull bones, invasion into the cranial vault with compression of the brain and surrounding structures, and infection of the brain including abscess.

    Surgery usually is curative but recurrences of cholesteatomas do occur.
    One retrospective case review of 51 patients (35 of which were <18 years of age) found in patients with normal hearing prior to surgery, 72% of patients had their hearing preserved within 10 decibels of their preoperative level.
    However, 26% of patients had cholesteatoma recurrence and had worse hearing outcomes.

    Acquired cholesteatomas usually are due to chronic middle-ear disease.
    They can occur when squamous epithelium enters the middle ear in some manne: after placement of pressure-equalizing tubes or other surgery, through a spontaneous perforation of the tympanic membrane, or most commonly through a retraction pocket.
    Retraction pockets are invaginations of the tympanic membrane.
    Chronic eustachian tube dysfunction causes a vacuun to be created in the middle ear.
    This vacuun then causes collapse in a focal area of the tympanic membrane most commonly in the posterior-superior segment of the pars tensa, or in the pars flaccida toward the attic, or in an old perforation or instrumented portion of the tympanic membrane.
    As the collapsed area invaginates and expands, it closes up into itself creating a space that is lined with squamous epithelium. The squamous epithelium produces keratin debris, further increasing the size of the lesion and expanding locally into contiguous structures.
    The expanding lesion can also become infected itself or cause infections in the middle ear secondary to further obstruction of the eustachian tube.

    Cholesteatomas can be difficult to diagnose. Sometimes there is only an impression that something is behind the tympanic membrane or that the structures look different than other middle ear disease.
    Cholesteatomas should be considered if there is a whitish mass behind the tympanic membrane, there is focal granulation tissue of the tympanic membrane, a deep retraction pocket, a draining ear that doesn’t improve after 2 weeks of treatment or new onset hearing loss in a previously operated ear.

    Learning Point
    Congenital cholesteatomas occur anywhere in the temporal bone but most often in the anterosuperior quadrant of the middle ear.
    The exact origin of congenital cholesteatomas is unknown but many people believe these come from squamous inclusion cysts arising from epithelial rests in the middle ear. These are seen during fetal development, but most disappear by the third trimester. The failed involution of these epithelial rests leads to the congenital cholesteatoma.
    Other theories include infection and microperforation of the tympanic membrane leading to introduction of squamous epithelium into the middle ear or seeding of the middle ear with squamous cells from the amniotic fluid.

    Questions for Further Discussion
    1. How are the ossicles reconstructed after cholesteatoma removal?
    2. How should patients with abnormal screening audiograms be evaluated and/or treated?
    3. What chronic diseases have an increased risk of middle ear disease and therefore an increased risk of cholesteatomas?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Ear Disorders and Ear Infections and at Pediatric Common Questions, Quick Answers for this topic: Chronic Middle Ear Infections

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1255.

    Smouha EE, Javanshir J. Cholesteatoma in the Normal Hearing Ear. Layngoscope. 2007;117;854-858.

    Isaacson G. Diagnosis of Pediatric Cholesteatoma. Pediatrics. 2007:120;603-608.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    July 21, 2008

  • What Are the Treatment Options for Oral Thrush in Young Infants?

    Patient Presentation

    A 3-month-old male came to clinic because his thrush had returned.
    He was a previously healthy, bottle fed infant who was growing normally.
    His parents had tried two courses of oral nystatin prescribed by physicians in the clinic and a course of oral fluconazole prescribed by an emergency room physician.
    He had stopped the fluconazole 3 days ago and today his parents noticed white patches again on his buccal mucosa.
    They stated that they always “painted” his entire mouth with the nystatin and sterilized his bottles and nipples by washing in a dishwasher.
    They had also bought new nipples recently.
    He did not use a pacifier or any other objects in his mouth.
    His parents were both healthy without any skin, oral or vaginal infections.
    The past medical history showed a second child in the family, born full-term without prenatal or natal complications.
    The review of systems was negative for any rashes including in his diaper area, infections, fever, or any problems eating.
    The pertinent physical exam showed a happy infant with growth parameters in the 75-90%.
    Oral examination showed some white patches on his buccal mucosa which did not scrape off and with minimal erythema around them.
    He did not have any rashes and the rest of his examination was normal.
    The diagnosis of recurrent oral candidiasis was made. The family was offered a choice of clotrimazole or gentian violet as treatment.
    They chose gentian violet and were instructed to again “paint” his entire mouth, tongue and palate with the dye three times/day for a minimum of 2 weeks and at least 3 days after the patches appeared to disappear.
    The physician did consider a possible immunodeficiency, but as the infant continued to have no problems with growth, infections or other problems elected to monitor the infant at that time.
    The family was also going to boil the nipples and bottles on their stove and family was to call or return before his 4 month well child care appointment if the thrush continued or returned.

    Discussion
    Oral candidiasis or thrush is most frequently caused by Candida albicans. Infants frequently acquire the organism perinatally or postnatally and it can be harbored in the oropharynx, skin and vagina.
    In healthy newborns 2-5% of infants are affected. Symptoms can include being asymptomatic, white plaques and/or erythema on the buccal mucosa, tongue, or palate that do not scrape off, chelosis of the angle of the mouth, and concomitant diaper dermatitis.
    Patients with underlying immunocompromising diseases such as AIDS, cancer and diabetes have thrush more commonly. Oral candidiasis is also more common in individuals using inhaled steroid medications. While oral candidiasis is usually a clinical diagnosis, microscopic examination by gram stain or potassium hydroxide can show yeast and pseudohyphae.

    Patients who are more than 6 months old with frequent relapses or persistence of oral candidiasis should be considered for an evaluation of an underlying immunodeficiency.
    Patients who are younger than 6 months with other symptoms of a possible underlying immunodeficiency should also be considered for evaluation.

    Learning Point
    Treatment for oral candidiasis for most healthy infants includes:

    • Nystatin oral suspension (100,000-200,000 Units four times/day) painting of the entire mouth is usually the initial choice and often clears the infection. Older children and adolescents may require 200,000-400,000 Units four times/day.
    • Gentian violet is a dye that has been used since 1925 for treatment of oral candidiasis. While it is overall less effective than other oral medications and can stain the mouth, clothing and other items, it can be effective. It is usually applied three times/day.
    • Clotrimazole is also an option and is used frequently for patients who are immunocompromised. It is dispensed as a troche (lozenge) and therefore cannot be used with young infants. Some physicians will recommend off-label use of clotrimazole (1%) vaginal cream four times/day for young infants.
    • Systemic antifungal treatment with other azole antifungals is often used in older infants, children and adolescents. These include fluconazole, ketoconazole or intraconazole. Again, these are used more often for patients with immunodeficiencies or other more serious yeast infections.

    Fluconazole (Diflucan®) is available in tablets and oral suspension (10 mg/ml or 40 mg/ml). Dosage is usually 6 mg/kg/day on day 1 and 3 mg/kg/day on subsequent days but for at least 2 weeks for oral candidiasis.
    In children 6 months to 13 years fluconazole has been shown to be effective for oral candidiasis. The drug has also been used in preterm infants for systemic candidiasis. Pharmacokinetic data is available for children 9 months and older, and also in preterm infants.

    Questions for Further Discussion
    1. What initial tests could be ordered for an initial immunodeficiency evaluation?
    2. At what age would you prescribe oral fluconazole for uncomplicated oral candidiasis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Yeast Infections and Mouth Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Vazquez JA, Sobel JD.
    Mucosal candidiasis.
    Infect Dis Clin North Am. 2002 Dec;16(4):793-82.

    Krol DM, Keels MA.
    Oral conditions.
    Pediatr Rev. 2007 Jan;28(1):15-22.

    Kalyousse S, Tolan RW, Greenberg ME. Candidiasis. eMedicine.
    Available from the Internet at http://www.emedicine.com/ped/topic312.htm (rev. 5/2/2007, cited 5/15/2008).

    Diflucan. RxList The Internet Drug Index.
    Available from the Internet at http://www.rxlist.com/cgi/generic/flucon.htm (rev. 2008, cited 5/15/08).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    July 14, 2008

  • I Don't Take Care of Adults, but Maybe I Can Still Help?

    Patient Presentation
    A 40-year-old female pediatrician had the unfortunate experience that adult family members and friends from different parts of the United States were diagnosed with
    brain, breast, colon, gynecological and hematological cancers
    in the span of one year.
    With each new diagnosis and different stages of treatment, her family and friends asked many questions, many of which she didn’t know the answers to herself.
    She did however want to help in some way, particularly since she lives apart from her family and friends.
    She went to the National Cancer Institute website to start looking for answers to their question and to learn herself.
    From there she quickly was able to review an overview of the disease, treatment options, and possible prognoses which helped her to understand the cancer and be able to answer their questions better.
    She also found information from the National Cancer Institute and different cancer organizations about common problems such as fatigue and nutrition.
    In some cases, she e-mailed the Internet addresses of the information to her family and friends and in other cases, she printed and mailed them the information.
    When her friend’s cancer returned, she searched the National Cancer Institutes’ Clinical Trials database and was able to help her friend enroll in a Phase 2 clinical trial.
    As her friend died and in the weeks and months afterwards, the information from hospice and different cancer organizations helped the pediatrician to better care for herself.

    Discussion
    Because of their knowledge, experience and a trusted relationship, health care providers (HCPs) are often asked by family, friends and acquaintances about health-related matters.
    HCPs are often turned to when a serious or life-threatening, new illness or disease is first diagnosed, as treatment plans are being developed, during the ups and downs of the course of the disease, and for end-of-life matters.
    HCPs have only a limited scope of practice and therefore are often asked questions about problems they do not treat or have less professional knowledge about.
    Yet as humans, HCPs want to help their family and friends in some way, even if it is just finding information for them.
    While this is true for almost any disease, cancer is a very prevalent disease and HCPs can expect that they may be asked cancer questions by family and friends.

    Some statistics:

    • In 2005, cancer was the second leading cause of death (22.88%) after heart disease (26.6%) in the United States.
    • The estimated number of cancer deaths in 2008 is ~1.4 million.
    • The lifetime risk of being diagnosed with cancer is 40%.
    • The lifetime risk of dying from cancer is 21%.

    Rare diseases are another area that HCPs may be as asked many questions about. Each disease by itself may not affect many patients, but the > 1000 rare diseases taken together may affect as many as 25 million people in the United States.

    Learning Point
    HCPs can help themselves by using various information resources and also giving similar information to their families and friends.

    The National Cancer Institute (http://www.cancer.gov/) offers a vast wealth of information itself, plus works as a clearinghouse, pointing patients and providers to other information resources.

    Detailed information about specific cancer types and treatment is available (http://www.cancer.gov/cancertopics/alphalist and at http://www.cancer.gov/cancertopics/pdq).
    This information is available in different degrees of detail for healthcare providers or patients and families. It is written in English or Spanish. When appropriate, the information is also stratified by age (i.e. adult versus child) or gender (e.g. prostate cancer for men, endometrial cancer for women).
    The HCP information is good for understanding the overall disease process, treatment and potential outcomes.
    This can assist the HCPs who are often asked many questions by their family and friends in translating or confirming the medical information understood (or misunderstood) by family and friends.

    HCPs are also often asked about cancer-related problems and how to deal with them.
    General cancer resources (http://www.cancer.gov/cancertopics/coping) are available for problems such as fatigue, pain, nutrition, sexuality, emotional issues, and supporting caregivers and other family members including children.

    Patients may be approached at the initial diagnosis or when a cancer recurs to be part of a clinical trial. The clinical trials section (http://www.cancer.gov/clinicaltrials) includes general clinical trial information but also access to a database for searching available clinical trials.
    Another clearinghouse of clinical trials for cancer and other diseases is Clinical Trials (http://www.clinicaltrials.gov/).
    Other clinical trials information may be available through cancer-specific organizations (e.g. American Cancer Society®, The Leukemia & Lymphoma Society®,) research institutions and professional cancer research organizations and networks.

    Many cancer-specific organization offer other information resources and may also sponsor local patient and family support groups (https://cissecure.nci.nih.gov/factsheet/FactsheetSearch.aspx?FSType=8.1).

    Information about rare diseases often comes from the research community and disease specific organizations.
    HCPs can use the Online Mendelian Inheritance in Man (http://www.ncbi.nlm.nih.gov/omim/) from the National Institutes of Health
    Genetics Home Reference (http://www.ghr.nlm.nih.gov/).

    Alternatively, authoritative medical information on the Internet for patients and families is collated by the National library of Medicines MedlinePlus® (http://www.medlineplus.org/) which indexes more than 750 health topics.
    Many people consider this the most comprehensive authoritative index on the Internet.

    Questions for Further Discussion
    1. What cancer clinical trials are available to patients within 50 miles?
    2. Your sister has just given birth and the baby is diagnosed with Shwachman Syndrome. Where can you find information to send to her?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Cancer, Cancer – Living with Cancer, and Evaluating Health Information.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ, Mariotto A, Miller BA, Feuer EJ, Altekruse SF, Lewis DR, Clegg L, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER web site, 2008.

    ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    July 7, 2008