3/12/2012

ClinicalPearls,MemoryAids,
Mnemonics,andaFewSmiles
BryanL.Burke,Jr.,MD,FAAP
UniversityofArkansasforMedical
University of Arkansas for Medical
SciencesandArkansasChildrens
Hospital

archildrens.org arpediatrics.org uams.edu

Disclosures
Ihavenothingtodisclose.
Idohavesomethingstoconfess,butthismay
notbetheappropriatevenue

archildrens.org arpediatrics.org uams.edu

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HowPeopleThinkisInteresting
Somedoctorsexpressedconfusionovermy
requestforclinicalpearls,memoryaids,and
tf li i l l id d
mnemonics Idontthinkthatway.
Somedoctorswerethrilledtosharetheir
favoriteones Iusethemallthetime.
Agoodpsychologistcouldprobablyexplain
A good psychologist could probably explain
thedifferentthoughtpatterns.
Ifallintotheusethemallthetimecamp.

archildrens.org arpediatrics.org uams.edu

Memory AsTimeGoesBy
Memory
Itisfortunatethatourclinicalacumenimprovesin
direct proportion to our inability to remember what
directproportiontoourinabilitytorememberwhat
wejustread.
FromMurrayFeingold,MD,ProfessorofPediatricsat
BostonUniversityandPhysicianinChiefatthe
NationalBirthDefectsCenterinBostonandthe
Joseph F Kennedy Memorial Hospital for Children in
JosephF.KennedyMemorialHospitalforChildrenin
Boston.

AJDC June 1986 The Editorial Board Speaks

archildrens.org arpediatrics.org uams.edu

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OneThingtoWhichDr.FeingoldCould
NotGetAccustomed
Certainacademictypeswho,althoughthey
h
haveneverbeenoutintherealworld,
b t i th l ld
continuallypuffontheirpipes,stareatthe
ceiling,andslowlybutpedanticallypontificate
andcriticizethephysicianinpractice.

archildrens.org arpediatrics.org uams.edu

Dr.FeingoldsThingsthatNever
Change
Quotinganarticlethatispoorlydocumented
b t
butagreeswithyourclinicalimpression.
ith li i l i i
Findingfaultwiththemethodologyor
statisticalanalysisofanarticlethatdoesnot
agreewithyourclinicalimpression.
You
Youaremorelikelytogetintotrouble
are more likely to get into trouble
clinicallywhenyoustartfeelingtooconfident
aboutyourdiagnosticabilities.

archildrens.org arpediatrics.org uams.edu

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TheNewLanguageofMedicine
Patientsarecustomersorconsumers.
Doctorsandnursesarehealthcareproviders.
Thesewordsdemeanpatients,doctors,and
nurses.
Thesewordsareeconomicandreductionistic.
Thesewordsendangertheessenceof
medicine.

archildrens.org arpediatrics.org uams.edu

TheNewLanguageofMedicine
Customersmustrelyoncaveatemptor let
th b
thebuyerbeware.
b
Suchasentimentfostersanadversarial
relationship notoneoftrust.
Makesamockeryofthebondbetweenthe
healer and the sick
healerandthesick.

archildrens.org arpediatrics.org uams.edu

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TheNewLanguageofMedicine
Patientderivesfrompatiens,tosufferorbearan
affliction.
affliction
Doctorderivesfromdocere,toteach.
Nursederivesfromnutrire,tonurture.
Thenewwordsignoretheessentialpsychological,
spiritual,andhumanisticdimensions thevery
thingsthatmakemedicineacallingandnotajob.
hi h k di i lli d j b

Hartzband and Groopman, NEJM, October 13, 2011.

archildrens.org arpediatrics.org uams.edu

Essentially theperfectscreenfor
Essentially
ignorance
Question Howdothelungssound?
Answer
A E
Essentially,clear.
ti ll l
Essentiallyisusedmedicallyasascreenfor
uncertainty.
TheresponsetoDoyoulikeRazorbackfootball?
wouldneverbeEssentially,yes.,becauseboth
partieswouldbehearingandspeakingEnglish,
i ld b h i d ki E li h
withoutobfuscation.
NP Christy. English is Our Second Language NEJM 300:979,
1977.

archildrens.org arpediatrics.org uams.edu

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VitalSignsandThermodynamics
Patientswhoarereportedtonothavea
t
temperatureviolateabasiclawof
t i l t b i l f
thermodynamics.
Perhapsequivalenttopatientswhodonot
haveanelevatedtemperature.

William Cleveland MD and Harry Cynamon MD. A

Fascinoma. Journal of Pediatrics October 1984. University of
Miami School of Medicine.

archildrens.org arpediatrics.org uams.edu

PatientPresentationAdvice
Whenyoubegintopresentthephysical
examinationfindings,thefirstwordsoutof
i ti fi di th fi t d t f
yourmouthshouldbethepatientsvitalsigns.
Iftheywereunimportant,theywouldbe
calledinconsequentialsigns.
FromThomasDungan,PediatricCardiologist
g , g
atArkansasChildrensHospital,1977.Advice
giventomeasaJMS,duringaparticularly
poorpatientpresentationonmypart.
archildrens.org arpediatrics.org uams.edu

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 3/12/2012

PenicillinAllergyintheFirstYearofLife
Everychildlessthan1yearoldpurportedto
h
haveapenicillinallergyhadacaseof
i illi ll h d f
roseola.
FromJ.O.Cooper,anElDorado,Arkansas
GeneralPediatrician,early1960s,asrelayed
byDaleDildyMD,anACHGeneralPediatrician
y y ,
2011.

archildrens.org arpediatrics.org uams.edu

DealingwithUncertaintyWhile
MakingaDifficultDiagnosis
AlwaystellthepatientIdontknowthe
di
diagnosisyet.
i t
Tellsthetruth.
Conveysconfidencethatthediagnosiswillbe
found.
Conveyshope
Conveys hope incrediblyimportant.
incredibly important
FromNewtDildyMD,aNashville,Arkansas
familydoctor,early1960s.

archildrens.org arpediatrics.org uams.edu

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AbbreviationEngenderedConfusion
Dontswabachildssorethroatifthe
epidemiologyandclinicalsettingareviral.
id i l d li i l tti i l
10%arecarriersforGroupAStrepsoyoull
justbetreatingfolkswithaviralpharyngitis.
TheabbreviationinPenVK(PenicillinV
Potassium) oralpenicillin
Potassium) oral penicillin doesnotstand
does not stand
forviruskiller.
DanMcGee,again.

archildrens.org arpediatrics.org uams.edu

HoarsenessandSoreThroats
Neverswabthethroatofanyonewhoishoarse.
Hoarsenessandlaryngitisarealwayscausedby
H dl iti l db
viruses neverbyGroupAStrep.
Thepatientdoesntneedtocometotheoffice,pay
forthevisitandthethroatswab,payforthe
penicillin,andriskStevensJohnsonsyndrome.
TomEdTownsend,GeneralPediatricianand
T Ed T d G l P di i i d
ArkansasSeniorPediatrician,PineBluff,Arkansas,
1979.

archildrens.org arpediatrics.org uams.edu

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KeepingUpWiththeLiterature
KeepingUpWiththeLiterature The
CircleofAcademicLife
MedStudent Readsentirearticlebutdoes
notknowwhatanyofitmeans.
tk h t f it
Intern Usesjournalasapillowduringnights
oncall.
Resident Wouldliketoreadentirearticlebut
eats dinner instead
eatsdinnerinstead.
ChiefResident Skipsarticlesentirelyand
readstheclassifieds.

archildrens.org arpediatrics.org uams.edu

KeepingUpWiththeLiterature The
KeepingUpWiththeLiterature
CircleofAcademicLife
JuniorAttending Readsandanalyzesentire
articleinordertopimpmedicalstudents.
ti l i d t i di l t d t
SeniorAttending Readsabstractsandquotes
theliteratureliberally.
ResearchAttending Readsentirearticle,
reanalyzes statistics and looks up all
reanalyzesstatistics,andlooksupall
references,usuallyinlieuofsex.

archildrens.org arpediatrics.org uams.edu

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KeepingUpWiththeLiterature The
KeepingUpWiththeLiterature
CircleofAcademicLife
ChiefofService Readsreferencestoseeifhewas
cited anywhere
citedanywhere.
PrivateAttending Doesntbuyjournalsbutlooks
forarticlesthatmakeitintoTime orNewsweek.
Emeritusattending Readsentirearticlebutdoes
notunderstandwhatanyofitmeans.

Howard Bennett MD. February 19, 1992 JAMA A Piece of My

Mind.

archildrens.org arpediatrics.org uams.edu

TAILSforMicrocyticAnemia
Thalassemia
AnemiaofChronicDisease
IronDeficiency
Leadpoisoning
Sideroblasticanemia
FromChristineBarrettMD,ChiefResidentat
ArkansasChildrensHospital,2011.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

PMS&Nephritic/Nephrotic
PMS&Nephritic/Nephrotic Syndrome
withDecreasedComplementLevels
PMS Youaredepressedwhenyouhave
PMS
PMS.
Poststreptococcalglomerulonephritis
Membranoproliferativeglomerulonephritis
SystemicLupuswithnephritis.
ChristineBarrettMD,ChiefResidentat
ArkansasChildrensHospital 2011.

archildrens.org arpediatrics.org uams.edu

BestOpeningParagraphinaLetter
fromaConsultanttoaReferringMD
Thankyouverymuchforthereferralof___,indeed
a complicated patient who history reminds me of in
acomplicatedpatientwhohistoryremindsmeof,in
itscomplexity,ayoungmanwhomIhadthedutyof
caringforincollaborationwithoneofthe
endocrinologistsat___hospital.Hefinallysaidto
meIhavedecidedthatifwhenIdieIgotoheaven,
Godwillexplain
p ___tome.Ontheotherhand,ifI
,
gotohell,Godwillmakemetakecareof___.
SourcecannotberevealedbutIstillhavethe1993
letter BryanBurkeMD.

archildrens.org arpediatrics.org uams.edu

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TheSixHyposofNewbornMetabolic
Acidosis
Hypothermia
Hypoglycemia
Hypoxia
Hypoperfusion
Hypoantibioticemia
Hypoenzymosis
FromRobertArringtonMD,Arkansas
ChildrensHospitalNeonatologist,late1970s.
archildrens.org arpediatrics.org uams.edu

TheNineBloodVesselsInvolvedina
Nuchal Cord
Umbilicalvein,2umbilicalarteries,2external
j
jugularveins,2internaljugularveins,and2
l i 2i t lj l i d2
carotidarteries.
Bytheway,whatisatightnuchalcord?
Explanationofthepathophysiology.
Howthisexplanationhelps.
How this explanation helps
FromRobertArringtonMD,Arkansas
ChildrensHospitalNeonatologist,2005.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

AcuteTreatmentofHypokalemia
AcuteTreatmentofHypokalemia
SeeaBigKDrop
Calciumgluconate Kayexelate
Alb t l
Albuterol Diuretic(potassium
Di ti ( t i
Bicarbonate wasting)
Insulin Dialysis
Glucose

From David Mills MD, General Pediatrician, Medical

University of South Carolina, 2011.

archildrens.org arpediatrics.org uams.edu

SOARtoEvaluateEars
See canyouseetheeardrum.Dowhatisneeded
to get a good view
togetagoodview.
Ossicles poorlyseenthedrumislikelybulging.
Wellseenitslikelyretracted.
Air ifpresentyouknowtheresaneffusionbecause
airandwaterareinterfacing.
Red
R d leastimportant.Brilliantredwithangry
l i B illi d ih
injection?Whiteoryellowduetopus?
BethSimpsonMD,GeneralPediatrician,Childrens
MercyHospitalinKansasCity,2011.
archildrens.org arpediatrics.org uams.edu

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 3/12/2012

SLUBI theoverlookedpartofthe
SLUBI
differentialdiagnosis
SLUBI Selflimitedundiagnosedbenign
illness.
ill
Lotsofweirdthingsjustgoawaywithoutus
everfiguringoutwhattheyare.Itsgoodto
haveanameforit.
ThomasNewmanMD,GeneralPediatrician
Thomas Newman MD General Pediatrician
andResearcherextraordinaire,Universityof
California SanFrancisco,2011.

archildrens.org arpediatrics.org uams.edu

TheSecretofLookingLikeaSmart
Doctor
Bethethirddoctortoevaluatethechild.
Generallytakesabout2weekstogettothethird
doctor.
95%ofkidsgetwellbythennomatterwhatyoudo,
sowhateveryoudoyoulllooksmart.
Forthatother5%,theylldeveloparash,cough,
fever,bloodydiarrheaorsomethingthatwilllead
youtothecorrectdiagnosis thusyouwilllook
smarterthanthefirst2docswhosawthechild.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

TheSecretofLookingLikeaSmart
Doctor
Thatswhywe(privatepracticepediatricians)so
frequently look better than the family practice or ER
frequentlylookbetterthanthefamilypracticeorER
docfromwhomthechildfirstsoughtcare.
Thatswhyacademiccenterssofrequentlylook
betterthanpediatriciansinprivatepractice bythe
timethepatientgetstheretheyareeitheraboutto
get well or so sick you can figure out what they have
getwellorsosickyoucanfigureoutwhattheyhave.
TomEdTownsend,GeneralPediatricianand
ArkansasSeniorPediatrician,PineBluffArkansas,
mid1980s.

archildrens.org arpediatrics.org uams.edu

TheMostUnderusedDiagnosticTool
Time.Ifthepatientisstable,watchthediseases
progress Inaddition
progress. In addition
RepeatingyourH&Palwaysrepresentsagood
investmentofyourtime.Newsymptomsandsigns
willoccur,orthepatientmayremembersomething
theyhadforgotten.Nothingelsewillgetyoutothe
right diagnosis as quickly and you wonttordera
rightdiagnosisasquickly,andyouwon order a
bunchoffoolexpensiveteststhatwonthelpthe
patientandmayharmthem.
Dr.Townsend,again.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

VITAMINSPApproachtoDecreased
VITAMINS
LevelofConsciousnes
LevelofConsciousnes
Vascular Intussusception 30%
I f ti
Infectious have decreased LOC as
havedecreasedLOCas
Toxins thefirstsign.
Accidents Neoplasm
Metabolic&Migraine SyncopeandSeizures
Psychiatric

From an article I cant find, read many years ago Bryan Burke.

archildrens.org arpediatrics.org uams.edu

TMP/SMXDosingandShakespeare
TMP/SMXDosingandShakespeare
WhoSaysIambicPentameterisDead?
ThecorrectdoseforliquidTMP/SMX One
t
teaspoontwiceadayforeverytenkilosyou
t i d f t kil
weigh.
Nevermorethatfourteaspoonstwiceaday,
asthatequalsanadultTMP/SMXDStablet.
BryanBurke,JuniorMedicalStudent,Arkansas
Bryan Burke Junior Medical Student Arkansas
ChildrensHospital,1977.

archildrens.org arpediatrics.org uams.edu

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CRASHF:TheDiagnosticSecretof
CRASH
KawasakiSyndrome
C Conjunctivitis
R Rash
A Adenopathy,cervical.
S Strawberrytongue.
H Handsandfeet,swollenandthenpeeling.
F Feverfor5days.
FromCarrieDrazbaMD,GeneralPediatrician
atRushChildrensHospital,Chicago,2011.
archildrens.org arpediatrics.org uams.edu

HomeDeliveryandWaterBirths
HomeDeliveryisforpizza.
WaterBirthsareforwhales.
FromMarilynEscobedoMD,Universityof
OklahomaNeonatologist,2011.
FromthesetwoopinionsaloneIcouldbe
convinced to vote for her for President such
convincedtovoteforherforPresident such
commonsenseisneededinWashington.

archildrens.org arpediatrics.org uams.edu

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Takayasu Disease=Pulseless
Disease=Pulseless Disease
ThereforewhenyouhaveTakayasuDisease,I
cantTakayupulse.
t T k l
FromDaleAlversonMD,Neonatologistatthe
UniversityofNewMexico 2011.

archildrens.org arpediatrics.org uams.edu

Hand&FingerAidforCyanoticHeart
Disease
Thumb one fortruncusarteriosus.
Twocrossedfingersfortranspositionofthegreat
T d fi f t iti f th t
arteries
Threefingersfortricuspidatresia.
FourfingersfortetralogyofFallot.
Fivefingerswigglingalongaroundfortotal
anomalouspulmonaryvenousreturn.
Multiplecontributors thefirstwasAnnKellamsMD,
GeneralPediatrician,UniversityofVirginia.

archildrens.org arpediatrics.org uams.edu

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SecretofSuccess
Itsnotyouraptitudebutyourattitudethat
d t
determinesyouraltitude.
i ltit d
RobertFiserMD,again.

archildrens.org arpediatrics.org uams.edu

Psychological/PsychiatricTherapy
Psychological/PsychiatricTherapy
HowtoExplainaTouchySubject
Ivemetafewpeoplewhoneededtherapy,butfar
more that could benefit from therapy
morethatcouldbenefitfromtherapy.
Youdontneed therapy(yourenotcrazy).
Youcouldbenefit fromtherapy(atrainedempathetic
listenertohelpyousortthroughyourproblems).
Makessomepatientsopentotherapywhootherwise
wouldnotbe.
ld b
FromChristopherFunesMD,OurLadyoftheLake
PediatricResidency,BatonRouge,LA 2011.(Most
beautifulresidencynameever.)
archildrens.org arpediatrics.org uams.edu

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 3/12/2012

HematuriaDifferential
HematuriaDifferential ABCDEFGKIJK
Anatomic:cysts/tumors Glomerulonephritis
Bl dd
Bladder:cystitis
titi Heme:bleeding
H bl di
Cancer:Wilmstumor diathesisorSSdisease
Drug:cyclophosphamide Infection:UTI
Exerciseinduced InJury
Factitious:Munchausen Kidneystonesor
hypercalciuria

Melinda Clark MD, General Pediatrician, Albany Medical

Center; Albany, New York 2011.

archildrens.org arpediatrics.org uams.edu

ChronicCoughinInfants
ChronicCoughinInfants CRADLE
Cysticfibrosis Dyskineticcilia
Respiratoryinfections
R i t i f ti Lung,airway,and
L i d
pertussis,rings,slings, vascularmalformations,
andairwaythings larygnotracheomalacia,
Aspiration TEfistula, vocalcorddysfunction
GEreflux,swallowing Edema CHF.
disorder

Melinda Clark, MD again.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

FineMotorDevelopmentandthe
Alphabet
Childrenlearntocopygeometricpatternsin
alphabeticalorder.
l h b ti l d
Circle,Cross,Square,Triangle,andDiamond
untilyougettothediamond,whichis
obviouslytwotriangles.
FromJudithAnnTheriot,MD
From Judith Ann Theriot MD Directorofthe
Director of the
GeneralPediatricClinicalResearchUnit,
UniversityofLouisville 2011.

archildrens.org arpediatrics.org uams.edu

ADDandTick
ADDandTickAssociatedInfectionsin
theSEareaoftheUSA
AllchildrenwithTickAssociatedInfectionsin
th SE
theSEareaoftheUnitedStatessufferfrom
f th U it d St t ff f
ADD AcuteDoxycyclineDeficiency.
FromRichardJacobsMD,Chairofthe
DepartmentofPediatrics,ArkansasChildrens
Hospital
p 2011.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

ArgyllRobinsonPupilofSyphiliticLues
Argyll RobinsonPupilofSyphiliticLues
LikeaLadyoftheNight accomodatingbut
notresponsive.
t i
Doyourememberwhataccomodationis?
Pupillaryconstrictionwhenfocusingonanear
object.Thesepupilsconstrictwith
accomodation but not in response to light
accomodationbutnotinresponsetolight.
StanfordShulmanMD,PediatricInfectious
Disease,NorthwestUniversity,Chicago,2011.

archildrens.org arpediatrics.org uams.edu

Definitionofa2yearold
Apsychoticdwarfwithagoodprognosis.
FromLenoreParksMD,GeneralPediatrician,
WakeForestUniversitySchoolofMedicine
2011.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

NAVELforFemoralAnatomy
Fromlateraltomedial:nerve,artery,vein,
emptyspace,lymphatics.
t l h ti
FromJimMarcinMD,PediatricIntensivist,
UniversityofCaliforniaatDavisinSacramento,
2011.

archildrens.org arpediatrics.org uams.edu

EstablishingRapportwithanAngry
Teenager
Askthemwhoseideaitwastocometoclinic.
A k
Acknowledgetheydonotwanttobethere.
l d th d t t t b th
Tellthemyoullgetthemoutasquicklyaspossible.
Askthemhowtheyseetheirparentsconcerns.
FromGeneShatzMD,AdolescentMedicine,Helen
DeVosChildrensHospitalinGrandRapids,MI
2011.

archildrens.org arpediatrics.org uams.edu

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DiGeorge SyndromeandCATCH
SyndromeandCATCH22
Congenitalheart(Rightsidedarch,conotruncal
defect ASD VSD)
defect,ASD,VSD)
Abnormalfacies
Thymicabsence
Cleftpalate
Hypocalcemia
Deletionat22q
FromAnnieChurchMD,ChiefofGeneralPediatrics,
UniversityofTennesseeatChattanooga 2011.

archildrens.org arpediatrics.org uams.edu

MUDPILESandIncreasedAnionGAP
Acidosis
Methanol Lacticacidosis
U
Uremia i Ethanolandethylene
Eth l d th l
Diabeticketoacidosis glycol
Paraldehydeand Salicyclates
propyleneglycol
Iron,isoniazid,
infection,inbornerrors
ofmetabolism
Annie Church again, the first of many with this response.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

FivePApproachtoFTT
Peeing chronicUTI,RTA,renaldamage.
Pooping CF,Hirschsprung,malabsorption.
Pumping CHF.
Pituitary cortisol,growthhormone
deficiency,hyperorhypothyroidism.
Parenting easilythebiggestcategory.
FromGregTrowbridge,GeneralPediatrician,
HelenDeVosChildrensHospital 2011.

archildrens.org arpediatrics.org uams.edu

NAACPsofEosinophilia
NAACPsofEosinophilia
Neoplasm
Allergy
Asthma
CortisolDeficiency
Parasites
FromGregTrowbridge,again.

archildrens.org arpediatrics.org uams.edu

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 3/12/2012

HowtoDecideifaPatientisReadyfor
Discharge
Ivealwaysfeltthatifyouwentintoa
h it l d ll d fi
hospitalandyelledfire,anyonewhocould
h ld
getupandleaveprobablydidntneedtobe
there.
Workswellevenonthoselessthan12months
oldifyouimaginetheycanwalk.
y g y
FromTomEdTownsend,MD,General
PediatricianandArkansasSeniorPediatrician
1978.
archildrens.org arpediatrics.org uams.edu

TheSecretofLife
Twotwins onealwaysoptimisticandhappy,
th th
theotheralwayspessimisticandsad.
l i i ti d d
RequiresmorethanIcanputonaslide,so
allowmetotellyouthestory.
FromTomEdTownsend,MD,General
Pediatrician and ArkansasSeniorPediatrician
PediatricianandArkansas Senior Pediatrician
themid1980s.

archildrens.org arpediatrics.org uams.edu

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