Medical board exams include questions in several different areas. A large percentage of these questions are focused on treatment interventions, as an appropriate treatment that a physician is expected to provide to the patients. Three main aspects of treatment are generally tested on the specialty board exams. These include:
- Features of specific treatment interventions
- Treatments provided to specific patient populations and to patients with specific disease variants
- Treatment algorithms
The purpose of this post is to help understand the importance of selecting the proper treatment for a pediatric patient belonging to a specific population or having a particular disease variant. The ability to select an appropriate treatment intervention for a specific form of a disease or for a specific population of patients may be frequently tested on the board exams. The questions that assess this aspect of the test taker’s knowledge are generally reserved for conditions for which particular treatment recommendations or guidelines have been well-established.
Consider the example of patients who need to be treated for diabetes but also suffer from chronic kidney disease (CKD). Glipizide is considered to be the sulfonylurea of choice for these patients. This is due to the fact that glipizide is metabolized by the liver and its clearance and elimination half-life is, therefore, not affected by a reduction in the estimated GFR (eGFR). As a result, it is not required to adjust the dose of glipizide in this specific population of patients (National Kidney Foundation KDOQI clinical practice guideline for diabetes and CKD: 2012 update).
Another example would be the treatment of women with Grave’s disease who are in the first trimester of pregnancy. Propylthiouracil (PTU) would be the antithyroid drug of choice in this specific patient population, as methimazole (MMI) may be associated with an increased risk of birth defects (Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum, 2017).
Example Exam Question for a Pediatric Patient
Question: On the fifteenth day after his birth, a preterm infant develops tachycardia and a fever of 101oF. The baby is feeding poorly and has become increasingly irritated and fussy over the past few hours. He is suspected to be suffering from neonatal sepsis. Which of the following medications may be avoided in this patient?
- Cefotaxime
- Ampicillin
- Ceftriaxone
- Gentamicin
- Cloxacillin
QUESTION EXPLANATION:
Empirical antibiotics should be administered as soon as neonatal sepsis is suspected. In the case of late-onset sepsis, third-generation cephalosporins may be used to provide adequate coverage for hospital-acquired pathogens, such as Pseudomonas species, Staphylococcus aureus, and coagulase-negative staphylococcus. However, the use of ceftriaxone in neonates, particularly those born prematurely, should be avoided, as it may lead to hyperbilirubinemia by displacing bilirubin from albumin binding sites. This can result in the development of bilirubin-induced neurotoxicity in this specific patient population.
Let us review the other options provided in the question. Cefotaxime is another third-generation cephalosporin; however, in comparison to ceftriaxone, it is less associated with biliary excretion and is less likely to alter bilirubin-albumin binding. Aminoglycosides, such as gentamicin, and broad-spectrum penicillins, like ampicillin or cloxacillin, are typically included in the treatment regimens used for neonatal sepsis and provide coverage for the most commonly seen pathogens in neonates, such as E.coli, L. monocytogenes, and GBS.
References:
Amin SB. Bilirubin Binding Capacity in the Preterm Neonate. Clin Perinatol. 2016;43(2):241–257. doi:10.1016/j.clp.2016.01.003
Shermadou ES, Mavrogeorgos G. Neonatal Sepsis. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531478/
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