DMS Alumni Reflections

I'll let you see this one," the wise pediatrician said with a smile.

The exuberant third year medical student leaped at the chance. Triumphant music filled his head. So did images of Norman Rockwell, Marcus Welby, and the young doctors on ER. This was one of his first chances to work-up a pediatric patient. Straightening his white coat and adjusting his stethoscope the novice knocked on the door and then stepped into the exam room.

Seated on his mother's lap was an orange baby. The seven month old looked at the budding clinician with his big eyes and smiled like sunshine. The little pumpkin started nonchalantly playing with his mother's car keys. As the student began questioning the baby's mother, it was hard for him to ignore the orange baby. It was why his mother had brought him to the doctor. She was worried because she found her son had turned orange suddenly; he was fine when he went to bed last night. The baby was not acting sick. He'd had no fever or really any other symptoms. He had been nursing well and eating his baby food just fine. His wet and dirty diapers were unchanged. He had been a healthy baby until that point, growing well with no other illnesses. Nevertheless, his mother was sure something terrible was wrong. "Will he be ok?" she asked.

The mother's worry spread to the medical student as he began to examine the Oompa-Loompa sitting in front of him. Systematically checking the baby as he had been taught, the student moved from chest to abdomen, checked under his diaper, and fully examined his skin and extremities. Other than skin that looked like it belonged to a carrot, nothing seemed to be abnormal. The patient was unfazed and unimpressed as he swiped at the green stethoscope dangling just out of reach. Saving the worst for last, the concerned student examined the head and neck of the infant, ending with the ears, mouth and throat. This brought the baby's ire as he cried vigorously at the intrusion. Still nothing wrong, well other than the Technicolor orange skin. Maybe I missed an enlarged liver, he thought as he finished his examination. "I'll be right back with your doctor," he said as he left the room.

The now worried student collected his thoughts before presenting the patient to the pediatrician. This baby is seriously jaundiced he thought. He may be suffering from liver disease. The possible causes for the infant's liver dysfunction raced through the student's brain as he snatched at past lectures from hepatologists, grappled with memories of liver pathology he had seen under the microscope, and stretched to recall the anatomy and histology of the liver

learned in those first few weeks of medical school two years ago. The student put the final thoughts of a brilliant diagnostic plan in place as his preceptor stepped out of another exam room. They walked into the cluttered office of the doctor to discuss the case.

The student clearly recounted the history and accurately described the physical exam of this orange infant. When it was time to put the case together, the student listed a differential that would have impressed Osler. He recommended an immediate transfer to Dartmouth Hitchcock Medical Center for lab tests and radiology procedures to isolate the cause of this orange baby's liver failure. As the presentation ended, the wise pediatrician smiled quietly. Maybe he was stunned by the brilliance. After a moment, he suggested two things: "Before we do all of that, let's go look at the baby's eyes, and then let's ask mom what he's been eating."

Together they went into the exam room holding the neon orange baby. The pediatrician reviewed the highlights of the history with the baby's mother as we looked at his big blue eyes surrounded by white sclera. He checked the baby's belly, just to be sure. "What has your baby been eating?" asked the student. The mom finally smiled as she answered, "My baby loves carrots and sweet potatoes. He really loves them. He won't eat anything else."

"He'll need to try some other foods for a while," said the doctor. He then reassured the mother and the student as he described the condition known as hypercarotenemia - a benign, reversible skin pigmentation problem that occurs in infants who eat too much yellow and orange baby food. The carotene pigments that give those foods their colors can deposit in the skin if ingested in high concentrations. While the skin turns bright orange, the sclerae remain white and the liver functions normally. When an infant is jaundiced, the sclerae also turn yellow. The baby's skin color will return when he stops eating foods rich in carotene.

An audible sigh of relief came from the mother as she thanked the doctor and took her happy orange baby home. "Pay attention to details in your history and physical. The answer to most clinical problems lies in the details of an accurate history and physical," the pediatrician advised the student. Your ability as a doctor will depend on taking your knowledge and translating it for your patients and their families in a thoughtful, confident, and reassuring way.

The student has not forgotten these lessons even to this day.

Pete Putnam, MD, DMS '97