What is the Differential Diagnosis of Hypokalemia?

Patient Presentation
A 14-year-old male came to the emergency room after he had an episode of loss of consciousness for 1-2 minutes.
He regained consciousness on the way to the emergency room.
He said he felt his heart racing and then loss consciousness. He has had 1 previous episode 9-12 months ago where he felt “shaky and weak”. Over the past month he has complained of general “weakness” but cannot describe it further. he says he has had fatigue for 4-5 years.
He has missed some school because of the weakness. He has also had some muscle cramps that were short-lived.
The family history was positive for heart attacks at an advanced age and some anxiety and depression. No arrhythmias or neurological problems were in the family.
The review of systems was negative including fever, recent illnesses, travel, unusual diets or eating behaviors, and sexual activity.
The pertinent physical exam reveals a well-developed adolescent with normal vital signs and growth parameters. He has normal skin and subcutaneous fat. HEENT had a normal dental examination. His heart had a normal rate and rhythm with no murmurs and good pulses.
He had a normal neurological evaluation. His mood revealed some minor symptoms of depression. The rest of his examination was normal.
The laboratory evaluation in the emergency room showed a potassium level of 2.6 mEq/L (normal 3.4-4.7 mEq/L) and magnesium of 1.0 mEq/L (normal 1.3-2.0 mEq/L).
He received potassium and magnesium supplementation by IV. An electrocardiogram was normal and his beta-HCG was negative. The rest of his laboratory evaluation was normal at that time including electrolytes, BUN, creatinine, phosphorous, glucose, liver and pancreatic enzymes.
He was hospitalized and repeated electrolytes, BUN, creatinine, glucose, creatinine phosphokinase, urinalysis, urine electrolytes and osmolality were negative.
An abdominal ultrasound and urine toxicology screen were also normal.
Consultation with cardiology and neurology were negative.
A screening evaluation for psychiatric illness confirmed some concerns for depression but a fuller evaluation was needed.
A nephrology consult was obtained and the diagnosis of Gitelman’s syndrome was considered.
As the patient’s clinical course had shown no abnormalities since initial presentation, he was discharged to home on oral potassium and magnesium.
He was to follow up with his local physician, psychiatrist and nephrologist for further evaluation and monitoring.

Discussion
Gitelman syndrome is a renal salt-wasting disorder that causes volume contraction and hypokalemia alkalosis. Hypomagnesemia occurs in ~50% of patients. It is an autosomal recessive disorder. Patients are born full term without polyhydramnios have normal weight gain and usually present in late childhood. They often crave salt. They may present with tetany or weakness secondary to hypomagnesemia. They also have low urinary calcium excretion.
Treatment is potassium and magnesium supplementation.

Bartter syndrome is often confused with Gitelman syndrome. Bartter syndrome also is a renal salt-wasting disorder that is autosomal recessive. These patients often have a history of polyhydramnios and prematurity. They commonly have failure to thrive in the first year of life. Older children also crave salt and may complain of muscle cramps or constipation because of chronic volume depletion secondary to renal salt losses.
Treatment is centered on electrolyte supplementation but hypotonia and failiure to thrive can be difficult to treat.

Learning Point
Potassium is important for cellular homeostasis and is the most common intracellular cation. Most potassium is intracellular and total body potassium is ~50 meq/kg of body weight. The kidney is the final homeostatic mechanism for total body potassium.
Potassium is filtered in the kidney and ~80% is reabsortion in the proximal tubule. Potassium is secreted in the descending limb of Henle
with reabsorbing in the ascending limb. Potassium is again secreted in the distal tubules and collecting duct. Overall renal handing of potassium is affected by urine flow rate, plasma and luminal potassium concentration, delivery of sodium and chloride, availability of other nonabsorbable ions (e.g. sulfate, phosphate) and diuretics.

The differential diagnosis of hypokalemia includes:

  • Gastrointestinal losses – normally the bowel secretes potassium into the lumen and reabsorbs sodium chloride
    • Stomach
      • Emesis
      • Nasogastric suctioning
      • Pyloric stenosis
    • Intestine
      • Diarrhea
      • Enema and laxatives
      • Enteric fistula
      • Malabsorption
      • Villous adenoma
    • Biliary system
      • Biliary drainage
  • Renal losses
    • Electrolyte abnormalities
      • Hypomagnesemia
    • Endocrine abnormalities
      • Cushing disease or syndrome
      • Congenital adrenal hyperplasia
      • Hyperaldosteronism
      • High renin states
      • Increased mineralocorticoid – medications such as Florinef&reg, chewing tobacco, licorice
    • Intrinsic renal abnormalities
      • Bartter’s Syndrome
      • Gitelman’s Syndrome
      • Renal tubular acidosis, types I or II
    • Medications
      • Antibiotics – e.g. amphotericin B, carbenicillin
      • Diuretics – especially thiazide, loop diuretics, osmotic diuretics
  • Shift to Intracellular space
    • Alkalosis
    • Barium intoxication
    • Familial hypokalemia Periodic Paralysis
    • Hypothismia
    • Na-K-ATPase stimulation – e.g. beta-2 agonists, catecholamines, insulin
  • Othis
    • Excessive sweating
    • Inadequate intake – e.g. anorexia nervosa or abnormal diets, over long time periods only 10 meq/L/day of K is sufficient to sustain life

Questions for Further Discussion
1. What is the laboratory evaluation for hypokalemia?
2. What is the differential diagnosis for hyperkalemia?

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: Metabolic Disorders

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

Bakerman S. Bakerman’s ABC’s of Interpretive Laboratory Data. 3rd Edit. Interpretive Laboratory Data, Inc. Myrtle Beach, SC. 412.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1652-53,1713.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathised.
    3. Informed decisions about diagnostic and thisapeutic 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.
    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 othis 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.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    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
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    Date
    February 6, 2006

  • What is in the Differential Diagnosis of an Abdominal Mass?

    Patient Presentation
    A 3-year-old male came to clinic because his parents noted that his abdomen was hard on the right side when they squeezed his abdomen while they were playing 2 days ago.
    The past medical history was normal.
    The family history was negative.
    The review of systems was negative including weight loss, chills, fever, sweats, bone or other pain, adenopathy, bleeding, bruising or change in bowel or bladder habits. He also had normal satiety and was eating well.
    The pertinent physical exam with normal vital signs, growth and development. Abdomen reveals a diffuse solid mass in the right mid- to upper quadrant. No splenomegaly was noted. Shoddy anterior cervical and inguinal nodes were noted. Skin examination was normal.
    The work-up showed normal complete blood count, erythrocyte sedimentation rate, lactate dehydrogenase, liver enzymes, and total bilirubin.
    The radiologic evaluation revealed a large mass that appeared adherent to the liver that did not appear to be arising from the kidney or the adrenal grand. The patient then had an alpha-fetoprotein level drawn that was significantly elevated and a surgical biopsy confirmed a
    diagnosis of hepatoblastoma. The child is undergoing chemotherapy to shrink the tumor and surgical resection is planned for the future.


    Figure 33 – Axial image from a CT scan of the abdomen performed with intravenous and oral contrast. A large, inhomogenous mass is seen on the right side of the abdomen, compressing the right kidney posteriorly. The mass did not appear to arise from the right adrenal gland or right kidney.

    Discussion
    Approximately 70% of liver tumors are malignant with hepatoblastoma predominating in those < 3 years and hepatocellular carcinoma becoming more common in older children.
    Hepatoendothelioma is the most common benign tumor. Liver tumors usually present as a painless abdominal mass but they can also cause weight loss, anorexia, fever or jaundice.
    Alpha-fetoprotein levels are elevated in hepatoblastoma and hepatocellular carcinoma. Hepatoblastoma is more common in children with Beckwith-Wiedemann syndrome and hemihypertrophy.
    Resection is the mainstay of treatment but chemotherapy to shrink a large tumor or after resection is also used. Favorable factors for prognosis are decreasing alpha-fetoprotein levels and complete resections.
    Overall disease free survival is 70% except for those patients presenting with initial metastatic disease.

    Learning Point
    The differential diagnosis of an abdominal mass depends on the location, age of the patient, and imaging results but includes:

    • Abdominal organs that are normal but are mistaken as a mass – e.g. liver, spleen, kidney, aorta, bladder, uterus, etc.
    • Organ enlargement – e.g. storage disease, congestive heart failure, infection, etc.
    • Gastrointestinal anatomic abnormality – e.g. bowel duplication, stenosis, appendiceal abscess, etc.
    • Renal abnormalitiy – e.g. hydronephrosis, megaureter, polycystic kidney disease, renal vein thrombosis, etc.
    • Tumors – primary or metastatic, but most commonly neuroblastoma, Wilm’s tumor, and lymphoma. Other malignancies include hepatocellular carcinoma, hepatoblastoma, rhabdomyosarcoma,
      ovarian or testicular germ cell tumors, and primary neuroectodermal tumors. Benign tumors may also occur such as teratomas.

    • Cysts – e.g. choledochal cyst, mesenteric cyst, pancreatic pseudocyst, omental cyst, ovarian cyst, meconium pseudocyst, urachal cyst, etc.
    • Miscellaneous – e.g. abscess, fecal mass, hydrops of gall bladder, intussusception, pregnancy, pyloric stenosis, hydrometrocolpos, adrenal hemorrhaage, etc.

    Questions for Further Discussion
    1. What should be included in the workup of an abdominal mass? Why?

    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: Liver Cancer

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

    Sheldon SH Levy HB. Pediatric Differential Diagnosis. Second Edition. Raven Press: New York. 1985:1-4.

    Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:115-120.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1375-1376, 1620-21.

    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.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    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.

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

    Date
    January 30, 2006

  • When Do Cyanotic Congenital Heart Diseases Present?

    Patient Presentation
    An 6 week old male came to his local pediatrician’s office with 2 days of nasal congestion that was clear. He was formula feeding without problems and had started daycare several days ago. He had no fevers.
    The past medical and social history revealed that he was a previously well, full-term baby.
    The family history was negative.
    The pertinent physical exam revealed a vigorous male with weight, length and head circumference in the 25-75% and growing appropriately. His heart rate = 135, respiratory rate = 30 and normal blood pressure. He was afebrile.
    He was noted to have purplish lips, hands and feet. He had clear nasal discharge.
    On heart examination, he had a grade III/VI systolic murmur loudest at the lower left sternal border that was described as high frequency. It was not holosystolic but occured through most of systole.
    There was a normal S1, S2 with a normal split of S2. There was no other murmurs or thrills.
    The liver was 1.5 cm below the right costal margin and a normal spleen was palpable. The peripheral pulses were equal in the upper and lower extremities. There was a 1.5 second capillary refill.
    The work-up after being transferred to the local hospital revealed a saturation of 68% and a hyperoxia test showed an increased in the saturation to 80%.
    The chest radiograph showed clear lung fields andno cardiomegaly.
    The electrocardiogram showed upright T waves in V1 and V2 and mild right ventricular hypertrophy.
    An arterial blood gas was normal. a dignosis of of cyanotic congenital heart disease was made, but the patient was also placed on intravenous antibiotics because of his age and possible co-existing sepsis.
    He was transported to a regional children’s hospital where an echocardiogram revealed the specific diagnosis of Tetralogy of Fallot. A cardiac catheterization was planned to determine anatomy, pressures and to plan probable surgery to increase pulmonary blood flow.

    Discussion
    Cyanosis is a blue coloring of the skin and mucous membranes caused by an increase concentration of reduced hemoglobin. This occurs at a critical level of about 5 g/100 ml of reduced hemoglobin.

    Cyanosis is caused by

    • Decreased arterial oxygen saturation
      • Inadequate alveolar ventilation
        • Airway obstruction
        • Structural changes in the lungs (e.g. pneumonia, hyaline membrane disease, etc.)
        • Central nervous system hypoventilation
        • Weakness of the respiratory muscles
      • Desaturated blood bypassing the lungs
        • Cyanotic congenital heart disease
        • Pulmonary arterio-venous fistulas
    • Increased capillary deoxygenation
      • Acrocyanosis of the newborn
      • Congestive heart failure
      • Shock
    • Abnormal hemoglobin
      • Carbon monoxide poisoning
      • Methemoglobinemia

    The hyperoxia test is a screening diagnostic test used to often determine if the cyanosis is caused by the circulatory or pulmonary systems. The infant is placed in room air and the saturation measured. The infant is then placed in 100% oxygen environment and the saturation is again measured.
    If the problem is in the lungs, the saturation should increase with supplemental oxygen.
    If the problem is caused by cardiac disease, the saturation should not improve with the supplemental oxygen. This is because there is still mixing of saturated and desaturated blood in the heart. The hyperoxia test is useful as a general test, but as each child’s cardiac anatomy may be different, the test may not show these results every time.

    Congenital heart disease occurs in ~10 /1000 live-born children. The incidence is higher in stillborn and spontaneous abortuses. The most common congenital heart disease is a ventricular septal defect and the most common cyanotic congenital heart defect is transposition of the great vessels.

    Common congenital heart disease incidence as a percentage of all congenital heart disease

    	Ventricular septal defect		27.1-42
    Atrial septal defect 6.8-11.7
    Patent ductus arteriosus 5.3-11 (excluding preterm infants)
    Transposition of the great vessels 3.5-5.3
    Tetralogy of Fallot 3.9-6.8
    Truncus arteriosus 0.7-1.7
    Total Anomalous Pulmonary Venous Return 0.6-1.7
    Hypoplastic right heart 1.4-3.2 (mainly tricuspid atresia and pulmonary atresia with intact ventricular septum)

    Learning Point
    As noted before, the anatomy of an child is highly individualized. But time courses for general symptom presentation can be considered for various congenital heart disease.

    Presents Almost Immediately at Birth

    • Transposition of the great vessels (D-transposition) – The aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle forming parallel systemic and pulmonary systems. Communication between the systems is required for the infant to survive. These communications can be an atrial septal defect, patent foramen ovale, patent ductus arteriosus or combinations of these.
      D-transposition usually presents with severe cyanosis at birth.

    • Tricuspid atresia – There is no direct communication between the right atria and right ventricle. Blood must go from the right atrium to the left atrium by an atrial septal defect or patent foramen ovale. A patent ductus arteriosus is the source of blood flow to lungs. There are several variants of tricuspid atresia and associated lesions may determine the presentation.

    Presents in the Perinatal Period

    • Truncus arteriosus – A single great vessel leaves the heart to supply coronary artery flow, aortic flow and pulmonary flow. There is almost complete mixing of the systemic and pulmonary blood. The degree of cyanosis is dependent on the size of the pulmonary arteries and the magnitude of pulmonary blood flow.
    • Total anomalous pulmonary venous return – The pulmonary veins fail to connect normally to the left atrium. Alternate pathways direct flow to the right atrium and then across an atrial communication. The admixture of blood at the atrial level and the right to left atrial shunt result in the cyanosis. When this lesion presents at birth, it is because of obstruction to the pulmonary veins.
    • Tetralogy of Fallot (also known as a “TET” or “blue TET”) – The are four abnormalities are: ventricular septal defect, pulmonic stenosis, right ventricular hypertrophy and an overriding aorta. The amount of restriction through the right ventricular outflow tract determines the amount of pulmonary flow and influences the amount of right to left shunt across the ventricular septal defect. The degree of cyanosis is a reflection of the amount of pulmonary flow.

    Presents after the Perinatal Period

    • Tetralogy of Fallot (also known as a “pink Tetralogy” or “pink TET”) – The amount of restriction through the pulmonary valve and right ventricular outflow tract is less severe and there may be left-to-right shunting through the ventricular septal defect until pulmonary stenosis progresses.
      “Tet spells” occur when there is a provocation of a fall in systemic resistance and fixed pulmonary obstruction is present. At these times, the flow across the ventricular septal defect fecomes right to left and the patient has a cyanotic spell.
      The spells are characterized by tachypnea, cyanosis and a shorter outflow murmur. Treatment includes calming the child, and increasing the systemic vascular resistance (i.e. knee-to-chest position, volume influsion or sedation) by slowing the heart rate (beta-blocker therapy) to allow longer diastolic filling. Oxygen can also be administered to the infant but if resisted can actually be counterproductive.

    Questions for Further Discussion
    1. What are the common chest radiographic signs of congenital heart disease?
    2. What congenital heart diseases are associated with chromosomal abnormalities?
    3. What congenital heart diseases are associated with maternal medications?

    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: Congenital Heart Disease
    and at Pediatric Common Questions, Quick Answers for these topics:
    Congenital Heart Disease and Heart Murmurs and Arrhythmias.

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

    Rudolph CD, et. al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1780-81.

    Robertson J, Shilkofski N. The Harriet Lane Handbook. 17th edition. Elsevier Mosby Philadelphia, PA. 2005:159-210.

    Park MK. Pediatric Cardiology for Practitioners. 3rd edition. Mosby. St. Louis, MO. 1996;114-128.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively 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 competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused case 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.

  • 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.

    Author
    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa
    Dr. D’Alessandro would also like to thank Dr. Jill Morriss, Professor of Clinical Pediatrics for her helpful suggestions in reviewing and improving this case.

    Date
    January 23, 2006

  • What are the Treatments for Persistant Cradle Cap?

    Patient Presentation
    A 2-year-old male came to clinic for his health maintenance examination. His mother has noticed that he still has cradle cap. She has tried baby shampoo, selenium sulfide shampoo, tar shampoos and mineral oil with scraping by a toothbrush.
    These treatments slightly improve the problem but it continues.
    The pertinent physical exam reveals a healthy toddler with some waxy, yellow, thick scale on the center of the scalp. The affected area is about 2 centimeters in diameter and is non-erythematous.
    The diagnosis of continued seborrheic dermatitis was made. He was referred to dermatology who recommended a short course of topical steroids to decrease the scale. Once the scale was controlled alternating use of baby shampoo and salicylic acid shampoo was recommended.
    If the scale returned, a short course topical steroids were recommended for control.
    The patient’s clinical course showed no scale after 3 weeks of daily topical steroid. The scale is well controlled with alternating baby and tar shampoos.

    Discussion
    Seborrheic Dermatitis or seborrhea is a scaly, crusty eruption usually of the face, scalp, post auricular, presternal and intertriginous areas of the skin.
    It commonly worsens with changes in humidity, seasons, or trauma. The cause is linked to Malassezia organisms and an abnormal immunological response with activated complement levels.
    It commonly occurs in the first few weeks of infancy and generally clears by 8-12 months of age. It can recur during puberty and adolescense.
    Cradle cap or infantile seborrheic dermatitis often occurs on the scalp and diaper area, but can spread to the face and back of the head. It has scales that are greasy, yellowish and thick.
    It is different from seborrheic dermatitis of adolescents and adults as it lacks the presence of follicular lesions.
    It is not pruritic and does not have the characteristics of atopic dermatitis.

    Learning Point
    The prognosis even without treatment is good as most cases of infantile seborrheic dermatitis clear within weeks. Complications include secondary bacterial or candidal infections.

    Treatment for infantile seborrhea includes:

    • Anti-seborrheic shampoos including alternating tar, salicyclic acid, zinc or selenium shampoos
    • Loosening of the scale by mineral oil or other similar oil with scrubbing several hours later.
    • Topical corticosteroids – low to medium potency, with or without sulfur or salicyclic acid

    Treatment for adolescent seborrhea includes:

    • Anti-seborrheic shampoos
    • Calcineurin inhibitors – pimecrolimus, tacrolimus
    • Topical corticosteroids
    • Antifungal medication – systemic medication may be helpful with recalcitrant cases

    Treatment for blepharitis (i.e. inflammation of the eyelids) includes:

    • Warm water compresses
    • Dilute baby shampoo or other non-irritating shampoo
    • Topical antifungal medications are controversial because of the location

    Questions for Further Discussion
    1. How does seborrhea differ from psoriasis?
    2. Is seborrhea related to atopic dermatitis?

    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: Dermatitis

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

    Hurwitz S. Clinical Pediatric Dermatology. 2nd Edit. WB Saunders Co. Philadelphia PA. 1993;62-63.

    Selden S. Seborrheic Dermatitis. eMedicine.
    Available from the Internet at http://www.emedicine.com/derm/topic396.htm (rev. 9/13/05, cited 11/23/05).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively 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.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

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

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

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

    Date
    January 17, 2006