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PHYSiOLOGY and Electrolytes Fluids SUGGESTED READING Anderson S. Garcia DL, Brenner BM. Renal and systemic manifestations of glomerular disease. In: Brenner BM, Rector FC Jr, eds. The Kidney, 4th ed, Vol II. Philadelphia, PA: WB Saunders Co; 1991;1831-1870 Briggs JP, Sawaya BE, Schnermann J. Disorders of salt balance. In: Kokko JP, Tannen RL, eds. Fluidc and Electro’ytes, 2nd ed. Philadelphia, PA: WB Saunders Co; 1990:70-138 Darrow DC. A Guide to Leanzing Fluid Therapy. Springfield, IL: Charles C Thomas Publishers; 1964 Finberg L, Kravath RE, Fleischman AR. Water and ElectroIytes in Pediatrics. Philadelphia, PA: WB Saunders Co; 1982 Fanestil DD. Compartmentation of body water. In: Maxwell MH, Kleeman CR, Narins RG, eds. Clinical Disorders ofFluid and Electrolyte Metabolism, 4th ed. New York, NY: McGraw-Hill Book Co; 1987:1-13 Guyton AC. The lymphatic system, interstitial fluid dynamics, edema, and pulmonary fluid and partition of the body fluids: Osmotic equilibria between extracellular and intracellular fluids. In: Guyton AC. Textbook ofMedical Physiology, 7th ed. Philadelphia, PA: WB Saunders; 1986:361371; 382-392 Holliday MA. Body composition, metabolism, and growth. In: Holliday MA, Barratt TM, Vernier RL, eds. Pediatric Nephrology, 2nd ed. Baltimore, MD: Williams & Wilkins; 1987:3-13 Reineck Hi, Stein JH. Sodium metabolism. In: Maxwell MH, Kleeman CR, Narins RG, eds. Clinical Disorders of Fluid and Electrolyte Metabolism, 4th ed. New York, NY: McGraw-Hill Book Co; 1987:33-59 Schwartz GJ, Haycock GB, Edelmann CM Jr, Spitzer A. Late metabolic acidosis: A reassessment of the definition. J Pediatr. 1979;95:102-107 Table 5. Normal Infancy Glomerular AVERAGE GFR ML/MINII.73 M AGE 2-8 days days 37-95 days 1-6 months 6-12 months 12-19 months 2-12 years with permLssion Heilbron glomerularfihtration rate DC, Holliday Pedlati in children, are correct statements regarding normal and abnormal body compositions except: A. Diarrhea represents an exampie of excessive losses of D. 14. True statements tive osmolality solute. regarding effec- for thirst are set at glucose. C. A normal serum osmolality of about 280 mOsm/kg is maintained by control of water balance. D. Most infants by I month of age can vaiy urinary concentrations of solute from 50 to of age. fluid corn- partment approximates 40% in both the infant and the adult. 1000 mOsm/L. correct statement garding basal metabolic (BMR) is: E. The serum proteins account for the normal difference between serum and intracellular re- rate A. The higher BMR of infants results from the greater contribution of “central organs” to body weight. B. The impact of fever on BMR necessitates a 10% decrease of estimated fluid for insensible loss for each degree cen- tigrade above normal. C. The basal energy expenditure of the liver is the single est factor in determining 13. hypercholestemle- be accurately estimated from measured serum concentrations of sodium, urea-N, and weight attains 20% by 3 D. 84. different levels of plasma osmolality. B. Total serum osmolality can A person’s extracellular water contribution to total The most Familial sponsible fluid compartment is determined by the quantity of sodium present because sodium ions contribute effective cx- years MA, al-Dahwi A, Kogan NephroL 1991; 5:5-11. of body fluids and their controls include all of the foilowing except: A. The osmoreceptors regulating release of ADH and those re- nemia-hypovolemia- E. The intracellular M E. Diabetes mellitus. edema sequence. C. The size of the extracellular 12. RANGE ML/MIN/1.73 mia. transcellular fluid. B. Current studies support the concept of the hypoalbumi- tracellular DurIng 17-60 26-68 30-86 39-114 49-157 62-191 89-165 PIR QUIZ 11. All of the following D. Rate (GFR) 39 47 58 77 103 127 127 4-28 Reproduced Expressing Filtration BMR of infants. In the adult, muscle mass counts for approximately 50% of the BMR. largthe ac- Factitious hyponatremia may occur in each of the following except: A. Hypothyroidism. B. Hyperglycemia. osmolality. 15. Of the following, the most correct statement regarding Hf-ion balance is: A. In the growing daily endogenous load approximates rnEq/day. child, the H-ion 8 to 10 B. The synthesis of “new” HCO3normally matches that consumed in buffeting endogeneous H-ion load. C. Greater renal resorption of D. HCO3results in higher serum HCO3levels in infants versus adults. A vegetarian diet adds to the daily H-ion load requiring elimination to maintain homeostasis. C. Addison disease. Pediatrics in Review VoL 14 No. 2 February 1993 79 ‘\ American Academy of Ped iat r ics Continuing Programs Annual Education Meetings Washington, DC October 30-November Spring Chicago, 3, 1993 20-24, Denver, 1993 Continuing Education 1994 Colorado April 23-27, 1994 Medical Courses Pediatrics 1993 Maui, Hawaii March 5-7, 1993 Pediatric Trends Traverse City, Michigan September 3-5, 1993 Stateof-the-Art Pediatrics New York, New York May 14-16, 1993 . Dallas, Texas October 22-26, Sessions Illinois March d State-of-the-Art . Pediatrics . Atlantic City, New Jersey September 29-October 1, 1993 . Pediatric Advances Hilton Head Island, South Carolina May 28-30, 1993 6th Annual Pediatrics in Progress San Francisco, California October 8-10, 1993 Clinical Pediatrics Washington, DC June 18-20, 1993 To those enrolled in PREP (Pediatrics Review and Education Program), these programs feature subject matter coordinated with the PREP curriculum. Credits earned in these courses may be applied toward the PREP Education Award available to Fellows and Candidate Fellows of the Academy. PREP: An Intensive San Diego, May 8-12, THE Review California 1993 COURSE of Pediatrics Pine Mountain, Georgia (one hour from Atlanta) October 15-19, 1993 For further information contact: CME Registration American Academy of Pediatrics P0 Box 927 Elk Grove Village, IL 60009-0927 800/433-9016 Outside the US and Canada: 708/228-5005 The American PR” P ‘#4/ Board of Pediatrics#{174} rog ram fo r Renewal of Certification in Pediatrics Guides for Record Review Chronic Abdominal Pain Supplement to Pediatrics in Review The Chapel American Board of Pediatrics 111 Silver Cedar Court Hill, North Carolina 27514-1651 @1993 by the American All Rights Board Reserved of Pediatrics This guide has been prepared by the American Board of Pediatrics (AB?) as an integral part of the record review required for renewal of certification in general comprehensive pediatrics. Its purpose is to provide the pediatrician with criteria for assessing patient records dealing with specific problems. Important elements to be included in the record appear in bold-face type in the margins; other elements to be considered are printed in italics. Theguides focus on the elements of the history and physical examination relevantto specific problems and are not meant to discourage a more thorough history and physical examination as appropriate for the patient and the particular circumstances. The guides knowledge these tional will be updated and their should be verified is included in each about guides units drugs periodically. availability, in current guide. Because drugs and sources. of rapid dosages A table changes in included in of interna- The guides are planned, written, and reviewed by an ABP committee composed primarily of practicing pediatricians. Appropriate subject experts are consulted during the preparation of the guides. . Please articulate solely Distribution Pediatrics note that standards to address of this guide through a license these guides do not purport of care They are 4esigned record keepIng Issues is made agreement possible by the American with the American Board to. Academy of Pediatrics. of INTRODUCTION Chronic or recurrent abdominal pain is one of the most common and challenging complaints evaluated by pediatricians.1 Depending upon the frequency and severity of the complaint and the child’s and family’s response to it, considerable school can be missed, and considerable expense entailed as a result of medical evaluation and therapy. The etiology has frequently been divided into organic, functional, and psychologic causes,2 but these are not mutually exclusive and all avenues should be explored in the evaluation of the child with chronic or recurrent abdominal pain. Functional pain is considered to be of probable organic origin (eg, hypermotility of the bowel) even though no organic cause can be identified; this type of pain should not be ascribed to psychologic causes if there is little or no evidence for psychopathology. This unit considers children from 3 years of age to puberty whose have been present for at least three months and have been characterized persistence or recurrence over that time period. PATIENT pains by IDENTIFICATION The age of the patient or birth date should be recorded because the common causes of abdominal pain tend to differ with age; for example, peptic ulcer disease and inflammatoryboweldisease are more common after lOyears ofage. Raceshould alsobe noted, for sickleceildisease isa causeofpaininblack persons, and lactose intolerance is a frequent cause of symptoms in black, Mediterranean, Indian, and Asiatic children older than 4 years ofage.3 Gender may be significant, for urinary tract infections and pelvic abnormalities are more common in girls. An up-to-date record of all immunizations should be a part of each child’s medical record. Finally, any drug allergies should be recorded prominently on the chart so that a drug to which the patient is sensitive is not prescribed inadvertently. PATiENT Birth date Race Gender Immunizations Drug allergies HISTORY A detailed description of the abdominal pain is essential to the interpretation of its likely cause. The location and any tendency to radiate should be noted, as well as the character, duration, and severity of the pain. Radiation of pain to the back occurs in posterior duodenal ulcer and pancreatitis, whereas pain from gallbladder disease radiates to an area between the scapulae. Epigastric pain isassociated withdistalesophagitis, gastritis,orulcer, and with pancreatitis. Leftupperquadrantpain may representgastritis,gas trapping,or lesions in the jejunum or splenic flexure of the colon. Pain in the nght upper quadrant is likely due to hepatobiliary disease, perihepatic inflammation, or duodenal ulcer. Right lower quadrant pain suggests appendiceal, ovarian, or inflammatory bowel disease. Left lower quadrant pain is usually caused by colitis or constipation. Periumbilical pain is less specific for an organic abnormality but it may represent small bowel disease. I Description of pain, including location, 5verftY,f1uency, character om ng Description of stools (eg constipation) Weight Loss gastritis, colomc Fever Family history of , sease Family history depression Social history il tory Characteristics of the pain and its duration are important; or ulcer pain is described as burning or gnawing, and pain as cramping. The pain of esophagitis, ulcer disease, bowel particularly pain, which of present tract neal esophagitis, small bowel or or inflamma- disease may awaken the patient from sleep; esophageal pain is prominent upon awakening, in contrast to functional abdominal rarely disturbs a child’s sleep. Peptic ulcer pain is most typically an hour or two after disease, or inflammatory pain is dull, aching, and meals. The pain of esophagitis, gastritis, biliary bowel disease is aggravated by eating. Peritoworsened by bumping or jumping motions. (eg, environmental or chronic stress) The effect of time ofday, physicalactivity, schoolattendance, and the like may provide clues to etiology. If the child is receiving any medication, a relationship between the drug and the pain should be explored. If the child has had previous studies or treatment for the complaint, the results should be recorded. Finally, the degree of incapacity (that is, the response of the child to the pain) should be noted; pain that interferes with school attendance, play activities, or sleep is of concern.4 The history should also include the presence of any weight loss or recent failure to gain weight, which would favor an organic cause. The child’s appetite and diet should be evaluated, particularly any unusual intake, such aslarge amounts offoods ormedicines containingsorbitol,6excessive amounts of fruit juice, or frequent ingestion of chocolate or popcorn. The history of vomiting and whether vomitus was bile stained or bloody should be noted in the chart. The presence of low-grade or recurrent fever may be a clue to inflammatory bowel disease or infection. Urinary tract disease is a common cause of abdominal pain, and its presence may be indicated by the complaints of dysuria, frequency, flank or suprapubic pain, and hematuria. The character ofstoolsshouldbeascertainedbecausethepresenceofblood ormucussuggests colitis, whereas fatty and foul-smelling stools indicate the possibility of malabsorption. Constipation may be one of the most common causes of persistent abdominal pain, so the frequency and hardness of the stools should be determined.’ Distention and flatus are clues to disorders such as lactose intolerance8 or giardiasis. The review evidence of other chest discomfort, withoutobjective if there is evidence of systems should be complete, but should particularly seek potentially functional complaints, such as headache, vague anorexia without weight loss, or joint and extremity pain manifestions.9”#{176}Thepreviousmedicalhistory maybe helpful of milk intolerance, gastroesophageal reflux, or encopresis. Children with functional recurrent abdominal pain usually are strung” and excitable, and may be apprehensive, timid, or perfectionistic. pattern ofover-reaction to minor illnessor injury maybeuseful as evidence the parent(s) may be overly anxious. “high A that The familyhistory should focusongastrointestinaldisease, such as peptic ulcer, spastic colon, and lactose intolerance. Because migraine and seizure disordersare causesofabdominal pain, though uncommon, a family history of these complaints may be helpful.4 A strong relationship between maternal depression and recurrent abdominal pain in her child has been reported, so evidence of psychiatric illness in the family may be important.11”2 The social environment history may shed and on thecontribution light on the degree of stress in the child’s ofchronic stress to the patient’s complaints. 2 PHYSICAL EXAMINATION Abdominal pain can be a manifestation of disease in many other organ systems, so a thorough, complete physical examination should be done. The height and weight should be recorded, because an impairment in growth can be an important clue to the presence of an organic cause of the pain. The temperature may be useful for reasons noted above. Given the possible presence of a urinary tract abnormality, the blood pressure should also be recorded. The resuitsofa detailed abdominalexamination should be available, including the presence of masses or enlarged organs, any tenderness or distention, and the description of the peristaltic sounds. A rectal examination may be useful to search for fecal or other masses, to ascertain the character of the feces, and to provide a specimen for examination for occult blood. LABORATORY AND RADIOLOGIC Height/length Weight pressure Blood Abdomen examination Rectal STUDIES Because most chronic and recurrent abdominal pain has no identifiable organic origin, no laboratory or radiologic study is absolutely indicated in every patient.”4 Rather, studies should be selected on the basis of the results of a detailed history and physical examination, and the most likely cause for the complaints. However, it is commonly desirable to perform a noninvasive and inexpensive series of screening examinations, negative results of which will reassure both the physician and parents that organic disease is less likely to be present. For example, a complete blood count may provide evidence of anemia, lead poisoning, parasitic disease or allergy (eosinophilia), and other causes of recurrent pain. An erythrocyte sedimentation rate may be helpful in considering a disorder such as inflammatory bowel disease. Several stool examinations for occultblood canbe helpful in identifying sources of bleeding, such as peptic ulcer or a Meckel diverticulum. A complete urinalysis and, in girls, a urine culture will be helpful in the elimination of urinary tract disease as the cause of abdominal pain. Depending upon the history, physical examination, and screening laboratory findings, further studies are sometimes indicated, but should not be done indiscriminately in the absence of adequate indication. These include stool pH and examination for reducing substances which may identify carbohydrate intolerance, and stool examinations for ova and parasites or bacterial pathogens. Stool studies for fat may be helpful in documenting suspected steatorrhea, and an excessive number of leukocytes in stool may be found in patients with various forms of colitis. Where available, breath hydrogen studiescan be usefulinconfirming the presence ofcarbohydrate intolerance.3”3 Ultrasonography is the least invasive method for evaluating renal or pelvic abnormalities and diseases of the gallbladder or biliary tract, providing that the radiologist is experienced with such examinations in children. X-ray studies of the abdomen may identify evidence of unsuspected constipation, abnormal gas patterns, calcifications, and some masses. Contrast studies such as upper gastrointestinal series and barium enema examination should be reserved for those situations in which there seems a reasonable likelihood that an identifiable disease will be found, rather than as screening procedures. Radioisotopic scans have been used in the identification of a Meckel diverticulum, although both false-positive and false-negative results have been reported. 3 Temperature Complete blood Erythrocyte sedimentation , , . ‘ll count rate I YSiS Urine culture Stool for occult blood TREATMENT Dietary counseling Drug therapy Treatment will be dependent upon the findings and the Specific treatment for specific abnormalities such as peptic ulcer inflammatory bowel disease is beyond the scope of this discussion, diagnosis. disease or which will focuson thechild with “functionalabdominalpain” for which noorganic origin is apparent or suspected. Both parents and the patient will need a careful interpretation of these findings, and a clear explanation of why no further studies are needed if that judgment has been made. Considerable reassurance may be required (see Patient Education). Many treatments have been used in the management of functional abdominal pain, with varying levels of success. The treatment of constipation, when present, may be helpful in reducing abdominal pain.1’ Dietary counseling,emphasizinga nutritiousdietwith adequatefiberand bulk,’6and the use of stool softeners may be helpful in children whose bowel patterns or physical findings indicate significant constipation. The cessation of sorbitol ingestion hasbeenassociated with reliefin a few patients,’and a trial ofa lactose-free diet may be worthwhile in patients thought to have lactose intolerance.8 Sources of anxiety and stress should be identified and an effort made to reduce pressure for performance in school, to reduce unnecessary stress, and to reduce intrafamilial tensions.1#{176} Relaxation techniques may be helpful in children old enough to cooperate, as for other types of chronic pain.’5 For the child who is missing considerable school and has no evidence of significant organic disease, regular attendance is mandatory. The prescription of antispasmodic drugs, antacids, or other medications is discouraged because they are seldom effective and tend to reinforce the idea that there is something wrong with the child, even though no disease has been identified. FOLLOWUP Regular followup visits EVALUATION Children with recurrent abdominal pain should beevaluated regularly in follow-up, with particular attention to growth and to any change in symptoms or findings on physical examination that may warrant further investigation. Continued support and reassurance must be given if there continues to be no evidence of organic disease, and previous instructions may need periodic reinforcement.1’ Continued efforts should be made to resolve family and school issues which may be contributing to environmental stress. Each visit should be documented in the patient’s record. The longer a child is observed and hasnoevidenceoforganic disease, thelesslikely itis thata hidden problem is being missed. When organic disease is suspected, consultation with a pediatric gastroenterologistmaybe indicated before an extensiveevaluation is initiated for suspected organic disease to direct the evaluation along appropriate lines (eg, upper or lower endoscopy to rule out esophagitis, gastritis, peptic ulcer, colitis, or other lesions).’”8 4 PATIENT EDUCATiON Education of the child and family is one of the most important aspects of management of this troublesome problem. Both need to be assured that the pain isreal, and thatthe child isnot malingering. The pediatrician should avoid stating that “nothing is wrong” or implying this by saying, “I cannot find anything wrong.” A physiologic explanation, including the possibilities that gastrointestinal motility is disturbed,’9 that intraluminal tension is increased, and that these may be particular responses to environmental stress (as occurs inadults)isoften helpful.”2’4’ Techniquesmay beused toreduceany secondary gain by the child, such as insistence on regular school attendance, continued responsibility for choresaround the home, and thelike. Considerable counseling may be needed to discourage parents from seeking multiple medical and surgical opinions for further diagnostic evaluations and treatment. If parental illness such as depression is thought tobe contributing to the problem, parents may be advised to seek help for themselves.” The recurrent nature of the problem, and the importance of periodic re-evaluation, should be stressed. The management of persistent or recurrent abdominal pain in childhood can be time-consuming and frustrating for pediatricians, but with a comprehensive approach to the possibility of functional, psychologic, or organic diagnoses; careful evaluation; and comprehensive counseling, considerable relief can be provided to the patient and his or her family. The pediatrician should keep in mind that no matter what the etiology of thecomplaint, thechild does hurt. 5 Counseling cause about of pain REFERENCES I . Coleman WL, Levine MD: Recurrentabdominalpain: and the aches of the cost. Pediatr Rev 8:143, 2. Olson A: Recurrent management. Pediatr 3. Wald A, Chandra abdominal pain 4. Levine MD, Rappaport thelonelinessofthelong-distance 1984 5. Barbero 6. Hyams JS: Chronic Pediatr 100:772, 7. abdominal Ann 16:834, R, Fisher of childhood. pain: 1987 approach LA: Recurrentabdominalpain physician. PediatrClin inchildhood. abdominal pain and in recurrent in schoolchildren: North Am 31 :969, PediatrRev4:29, 1982 caused by sorbitol malabsorption. to clinical 47:666, findings 1972 in children I 1982 SB: Transit abdominal time pain. 8. Liebman WM: Recurrent intolerance, a prospective 9. OsterJ: Recurrent and adolescents. related Pediatrics abdominal Pediatrics pain, 50:429, headache, 1972 and Robinson DP, Greene JW, Walker LS: Functional adolescents: relationship to negative life events, characteristics. J Pediatr 1 13:588, 1988 Ii. Hodges K, Kline JJ, Barbero with recurrentabdominalpain 12. Zuckerman community 13. Barr RG, WatkinsJB, excretion: comparative nonspecific abdominal 14. Feldman W, McGrath P, Hodgson management of simple, childhood, Am J Dis Child 139:1216, 1985 15. Olness ment. limb Czinn SJ, Speck 114:670, 1989 17. Caulfield endoscopy North WT: sucrose in children complaints in and family G, et al: Depressive symptoms and in their families.JPediatr in children 107:622,1987 and headaches 79:677, 1982 in a PermanjA: Mucosal function and breath hydrogen studies in the clinical evaluation of children with complaints. Pediatrics 6&526, 1981 K: Hypnotherapy: 16. pains somatic self-concept, B, Stevenson J, Bailey V: Stomachaches sample of preschool children. Pediatrics Clin with abdominal pain in children: lactoseand study. Pediatrics 64:43, 1979 10. Pediatr the aches to diagnosis SE, et al: Lactose malabsorption I Pediatr 100:65, 1982 GJ: Recurrentabdominalpain Dimson recurrent an the costof 1986 Am C, et al: The use of dietary fiber idiopathic recurrent abdominal a cyberphysiologic 36:873, 1989 Campylobacter pylon: strategy a new in pain pathogen. M, Wyllie R, Sivak MV Jr. et al: Upper gastrointestinal in the pediatric patient. J Pediatr 115:507, 1989 6 in the pain. manage- J Pediatr tract 18. Steffen patient. RM, Wyllie R, Sivak MV Jr, et al: Colonoscopy J Pediatr 115:507, 1989 19. Pi#{241}eiro-Carrero VM, Andres JM, Davis RH, et al: Abnormal denal motility in children and adolescents with recurrent abdominal pain. J Pediatr 113:820, 1988 7 in the pediatric gastroduofunctional CONVERSION TABLE INTERNATIONAL I. II. III. IV. TO STANDARD (SI) UNITS Hematology Hemoglobin g/dL x 0.155 Platelets/mm3 Leukocytes/mm3 Erythrocytes/mm3 Hematocrit % x 0.01 Reticulocytes % x 0.01 Blood Pressure mm Hg (tori) = mmol/L count/p.L = 10’ cells/L count/jLL = 10’ cells/L count/j.LL = 10’ cells/L vol RBC/vol whole blood (1) = mbar = = = = = x 1.333 Blood Gases 1 mm Hg = 133.322 Base excess mEq/L = mmoVL pH value = same Pa PCO2 mm Hg x 0.1333 P02 mm Hg x 0.1333 Blood Chemistries Acetone mg/dL x 0.1722 Acetaminophen ig/mL x 6.62 Albumin g/dL x 144.9 or gIL x 14.49 Aldosterone ng/dL x 0.0277 Ammonia mgN/dL x 0.714 Bicarbonate mEjL Bilirubin mg/dL x 17.10 Blood urea nitrogen mg/dL x 0.357 Calcium mg/dL x 0.25 Carotene IU x 0.6 or jig/dL x 0.01863 Ceruloplasmin mg/dL x 0.0662 Chloride mEq/L Cholesterol mg/dL x 0.0259 Complement component (C3) mg/dL x 0.01 Copper j.Lg/dL x 0.157 Cortisol j.tg/dL x 27.59 Creatine mg/dL x 76.26 Creatinine mg/dL x 88.40 Digoxin ng/mL x 1.28 Enzymes Alanine aminotransferase (ALT, SGPT) U/L Aldolase Sibley-Lehninger units/mL Amylase Somogyi units/dL Aspartate aminotransferase (AST, SOOT) U/L Creatine kinase (CK) U/L Phosphatase Bodansky units/dL King-Armstrong units/dL 8 = mmolIL j.tmol/L j.tmol/L nmol/L mmol/L mmol/L p.mol/L mmol urea/L mmol/L jig jimol/L = j.unol/L = = = = = = = = = = = mmolfL mmol/L g/L j.unol/L nmol/L p.mol/L jimol/L nmol/L = U/L = U/L = U/L = U/L U/L = = = = = = = = = = U/L U/L = = kPa kPa Fatty mg/dL x 0.0354 ng/mL x 1 a,-Fetoprotein ng/mL x 1 Fibrinogen mg/dL x 0.01 Folic acid jig/dL x 22.65 Glucose mg/dL x 0.0555 Glycerol mg/dL x 0.1086 Haptoglobin mg/dL x 0.01 176 17-Hydroxyconicosteroids mg/d x 2.759 Insulin IU x 0.04167 or jiU/mL x 1.0 Iodine jig/dL x 78.8 Iron p.g/dL x 0.1791 Iron binding capacity j.tg/dL x 0.1791 17-Ketosteroids mg/d x 3.467 Lead j.tg/dL x 0.0483 Lipoprotein mg/dL x 0.01 Magnesium mg/dL x 0.4114 or mEq/L x 0.5 Phosphorus mg/dL x 0.3229 Potassium mEqjL Prednisone mg x 2.79 Protein g/dL x 10 Salicylate mg/dL x 0.0724 Sodium mEq/L Theophylline jig/mL x 5.55 Thyroid-stimulating hormone p.U/mL x 1 Thyroxine jig/dL x 12.87 Transferrin mg/dL x 0.01 Triglycerides mg/dL x 0.01 Triiodothyronine ng/dL x 0.0154 Urea nitrogen mg/dL x 0.357 Uric acid mg/dL x 59.48 Vitamin A j.tg/dL x 0.0349 Vitamin B12 pg/dL x 0.738 Vitamin C mg/dL x 56.78 Vitamin E jig/dL x 2.322 Xylose mg/dL x 0.0667 Zinc j.tg/dL x 0.153 acids Ferritin V. VI. VII. Urine or Stool Coproporphyrin jig x 1.53 Epinephrine jig/d x 5.458 Vanilmandelic acid mg/d x 5.046 Homovanillic acid mg/d x 5.489 Energy Kcal x 4.1868 Rad x 0.01 Radionuclide Curie (Ci) mmol/L p.gL = = = g/L nmol/L = mmol/L = mmol/L = jimol/L = jimoVd = mg = mU/L = nmol/L = j.tmol/L = jmiol/L = .unol/d = jimol,t = g/L = mmol/L mmol/L = mmol/L = mmol/L = j.tmol = giL = mmol/L = mmol/L = jimol/’L = mU/L = nmol/L = g/L = gIL = nmol/L = mmol urea/L = p.mol/L = jimol/L = pmol/L = p.mol/L = j.unol/L = mmolfL = jimol/L = = = = = = = KJ (Kilojoule) Gy (Gray) (joule/kg) = GGq = Activity x 37 9 nmol nmol/d jimol/d jimol/d (Gigabecquerel)