Patients with severe or significant GI bleeding
Order immediate blood studies, including type and cross-match, CBC, PT and PTT, and electrolyte panel with liver function studies. b. Insert a nasogastric tube. Nasogastric aspirate that is positive for occult blood will differentiate upper GI from lower GI bleeding. If gastric contents clear following initial lavage, gastric irrigation can be performed every 15 minutes for 1 hour, and than every 2-3 hours to assess continued bleeding. 4. Medications. Early use of antacid therapy and an H2...
Airway Devices
A 3-year-old boy who was recently admitted from the emergency department with respiratory distress has a room-air pulse-oximetry reading of 89 . A. Is patient truly hypoxic or is the pulse-oximetry reading an artifact of measurement Motion and improper oximeter probe placement may lead to falsely low readings. If pulse tracing is strong and corresponds to the heart rate, and the reading remains low, provide oxygen and examine patient. B. What is patient's ventilation and hemoglobin...
Pertinent Historical Information
If an infant, is there a family history of parathyroid disease or hypocalcemia A birth history of trauma or asphyxia 2. Are there renal symptoms (polyuria or polydipsia) GI complaints (eg, loss of appetite, nausea, constipation, weight loss) CNS symptoms (weakness, fatigue, depression) III. Differential Diagnosis. Infantile causes of hypercalcemia are often very different from causes in childhood. The two most common causes of hypercalcemia in adults, primary hyperparathyroidism and malignancy,...
Differential Diagnosis
The most common type in patients showing no evidence of structural, endocrine, or metabolic disease. B. Congenital Anomalies of Neuromuscular Function. Consider when constipation is evident in infancy. Includes congenital agan-glionic megacolon or Hirschsprung disease, intestinal neuronal dysplasia, and chronic intestinal pseudoobstruction. C. Structural Anomalies. Often evident on inspection (eg, imperfo-rate or ectopic anus, anal stenosis, anteriorly displaced anus...
Indications for Dialysis
Fluid overload that is refractory to medical therapy and is associated with heart failure or severe hypertension. 2. Hyperkalemia or metabolic acidosis that is refractory to medical management. 3. Severe hyponatremia or hypernatremia that cannot be corrected medically. 4. Symptomatic uremia (drowsiness, nausea and vomiting, irritability) usually seen as BUN exceeds 100 and approaches 150 mg dL or is rapidly rising at > 30 mg dL day. 5. Supportive dialysis for fluid removal to allow adequate...
Physical Exam Key Points
Patient may be orthostatic (decrease in systolic BP of 10 mm Hg or increase in heart rate of 20 beats min 1 minute after sudden movement from supine to standing position), suggesting acute blood loss. 2. Skin. Petechiae or purpura may be seen with thrombocytopenia in bone marrow failure or infiltration, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, or autoimmune hemolytic anemia. Telangiectasia, palmar erythema, and jaundice may indicate...
Platelet clumping due to activation during collection
Review peripheral smear and check platelet size. TABLE I-26. DIFFERENTIAL DIAGNOSIS OF THROMBOCYTOPENIA DURING CHILDHOOD TABLE I-26. DIFFERENTIAL DIAGNOSIS OF THROMBOCYTOPENIA DURING CHILDHOOD AIDS acquired immunodeficiency syndrome HIV human immunodeficiency syndrome HUS hemolytic uremic syndrome ITP idiopathic thrombocytopenic purpura SLE systemic lupus erythematosus TAR thrombocytopenia with absent radii. AIDS acquired immunodeficiency syndrome HIV human...
Malnutrition
Chronic Nonspecific Diarrhea (Toddler's Diarrhea). Typically occurs in children aged 1-3 years. Children appear healthy and continue to grow and develop normally. Excessive fluid intake and an unbalanced diet that consists mostly of low-residue, high-carbohydrate, and low-fat foods may play a role. F. Lactose Intolerance. Frequent cause of chronic diarrhea in pediatric patients. Often associated with bloating and flatulence. Milk or milk products exacerbate the diarrhea. Congenital lactase...
Voiding cystourethrogram VCUG
Obtain if central lesion suspected. 4. Urinary concentrating ability (water deprivation test). In young children, this test should be completed in-hospital to allow for monitoring of body weight and electrolytes (exclude hypernatremia). Impose water restriction while assessing urine osmolality, body weight, and vital signs. Terminate test if tachycardia or hypotension develops. In these children, if administration of nasal desmopressin acetate (DDAVP)causes an increase in urine...
Radiographic and Other Studies
Required in any febrile neonate (0-2 months) or any older infant or child with unexplained fever and mental status alteration to evaluate for meningitis. 2. Skeletal survey. Required in cases of suspected nonacciden-tal injury or to confirm a fracture suspected during palpation of a tender extremity. 3. CT scan of head. Required if there is any suspicion of trauma or abuse or increased ICP, or in the presence of focal neurologic signs, seizures, retinal hemorrhages, or...
Anemia With Hemodynamic Compromise or Complications
If patient is hemodynamically unstable, transfuse immediately. 2. If evidence of acute bleeding, stop bleeding and obtain adequate IV access (anticipating need for transfusion). B. Anemia Without Hemodynamic Compromise or Complications. Proceed with workup in an orderly fashion. Laboratory testing is not always diagnostic, and bone marrow biopsy may be indicated. C. Iron Deficiency Anemia. Alter patient's diet as indicated to prevent recurrence or persistence. Sample stools for occult blood,...
Plan
Evaluate height, weight, weight-for-height, vital signs, and signs of dehydration. If patient is dehydrated or severely malnourished, hospital admission may be advisable. Goals of nutrition support must be delineated. Calculate child's energy needs. Can patient be enterally fed If so, with what solids or formula products, and by which route B. Enteral Nutrition. Can be delivered by mouth nasogastric, naso-duodenal, or nasojejunal tube or gastric or jejunal tube. 1. Infant...
What precipitates pain Are there associated symptoms
Chest pain precipitated by exercise should be taken seriously (suggesting cardiac disease or, more commonly, exercise-induced asthma). History of trauma, rough play, or choking on a foreign body may be relevant. Chest pain associated with syncope or palpitations is more significant and may also relate to cardiac disease. History of fever suggests an infectious process (eg, pneumonia, myocarditis). C. What is patient's past medical and family history Past medical history may reveal asthma that...
Immediate Questions
What are the vital signs Because infants are diaphragmatic breathers, distention may impair respiratory function and cause tachypnea. Massive distention can compromise cardiac output, resulting in hypotension and tachycardia. Fever suggests infection, such as peritonitis or pneumonia, which can cause distention from adynamic ileus. B. Is abdomen usually distended Abdominal distention resulting from obesity and fecal retention occurs gradually, whereas that from intestinal obstruction is more...
Is there a history of polyuria polydipsia or excessive thirst
Diabetes insipidus or mellitus may cause hypernatremia if patient has no access to, or poor intake of, fluids, especially water. E. Is there a disorder of osmoregulation Central diabetes insipidus is caused by undetectable or low concentrations of plasma antidiuretic hormone (ADH). Patients have sudden onset of polyuria and a predilection for cold water. Nephrogenic diabetes insipidus has variable onset and is due to insensitivity of the renal collecting duct to ADH. Hypodipsic essential...
Migraine Management
Can be managed with symptomatic medication use (ie, when headache occurs, take an analgesic medication). These medications include acetaminophen, aspirin, NSAIDs, and a variety of combination medications (containing butalbital, caffeine, and codeine), such as Midrin and Fioricet. Triptans (eg, sumatriptan, rizatriptan, zolmitriptan, and naratriptan) can be used for infrequent headaches occurring less than once per week. Triptan medications are effective in treating...
Hypoglycemia
A previously healthy 3-year-old boy is brought to the emergency department in the early morning after his parents found him difficult to arouse. The family had been traveling and the child had a prolonged fast. His blood glucose level is 28 mg dL. A. What constitutes a low serum glucose level in a patient of this age Hypoglycemia in children is defined as follows. 1. Term neonate. Serum glucose < 50-60 mg dL. 2. Infants and young children. Serum glucose < 45-60 mg dL. 3. Older...
EGI disorders
Rectal exam is diagnostic and often therapeutic. 2. Gastroesophageal reflux. May cause excessive crying, as well as frequent regurgitation or vomiting, failure to thrive, hiccups, episodes of stiffening or arching or head tilting associated with feedings (Sandifer syndrome), recurrent wheezing or pneumonia, stridor, and obstructive apnea. 3. Milk-protein allergy. Seen in a minority of colicky infants. Other clues to the diagnosis include vomiting, diarrhea, heme-positive or...
Constipation
A 4-year-old boy has infrequent and painful bowel movements. A. What is patient's usual pattern of stooling Normal frequency varies from 4 times daily in infants to once every 3 days in children. B. Age at onset of symptoms Consider congenital anomalies, obstruction, or chronic diseases if constipation has been present since infancy. Functional constipation starts in toddler or preschool years. C. Consistency and size of stool Hard, large stool that is painful to pass is consistent...
Postinfectious nephritis streptococcal or other causes
Normal C3 occurs with viral upper respiratory infection. 3. Henoch-Schonlein nephritis. Systemic findings include rash, abdominal pain, and joint problems. 4. Chronic nephritis. Focal segmental, membranous, or membranoproliferative disease usually causes significant proteinuria. 5. Lupus nephritis. Low C3 other systems may be affected. 6. Vasculitis. Scleroderma, Wegener granulomatosis, or pol-yarteritis nodosa.
Miscellaneous Causes Pain Related to Underlying Diseases
Children with vasoocclusive crisis may have pain that localizes to the chest or produces acute chest syndrome. 2. Marfan syndrome. May result in chest pain and fatal dissection of an abdominal aortic aneurysm. 3. Herpes zoster infection. Shingles may produce severe chest pain that precedes the classic vesicular rash by several days or occurs simultaneously. 4. Coxsackievirus infection. This common viral infection may lead, rarely, to pleurodynia with paroxysms of sharp pain...
Oropharynx or Nasopharynx Postnasal drip from allergic or
Infectious rhinosinusitis is a common cause of cough. C. Larynx. Congenital abnormalities (eg, laryngotracheal cleft) or viral infections cause croupy cough. D. Tracheobronchial Tree. Irritation of mucosal receptors or retention of secretions can result in cough. 1. Bronchospasm. Asthma is a frequent cause of cough that can be productive and paroxysmal. 2. Congenital abnormalities. Includes tracheoesophageal fistula, cysts, and vascular rings. 3. Bronchitis. Includes infectious or inflammatory...
Metaiodobenzylguanidine MIBG radionuclide scan If
Pheochromocytoma is strongly suspected, obtain this study in tandem with MRI scan of abdomen. ECG. Quick and easy way to evaluate heart for left ventricular hypertrophy. Ambulatory BP monitoring. Best way to establish the diagnosis of office hypertension. School nurses are the poor person's ambulatory BP monitors. A. Hypertensive Emergency. Hypertension associated with signs of end-organ damage (pulmonary edema, hypertensive encephalopathy, cerebral bleeding, or cerebral infarction) requires...
Physical Exam Key Points 1 General features of exam
Most important purpose of exam is to reassure child that he or she is or will be physically all right. Other purposes are to document physical or forensic findings produced by sexual contact, screen for sexually transmitted infections, and look for physical findings indicative of other medical conditions. Most physical exams of sexually abused children will not yield any specific physical findings for sexual contact. b. Preparation. Exam should not require physical force. It is...
Hemolytic uremic syndrome HUS
Alport syndrome (hearing loss) thin membrane disease (little proteinuria). Hematuria From Kidneys That Is Not Glomerular 1. Interstitial disease (usually with proteinuria). Analgesic nephropathy, toxins (heavy metal, drugs) eosinophils may be present in urine. 2. Infections (pyelonephritis, tuberculosis). Always associated with pyuria. 3. Malformations. Cystic disease (family history) obstructive disease (can occur with minimal trauma) vascular problem (hemangioma,...
Urethritis
Suspect when dysuria, pyuria, but no bacteriuria, is present. Treatment with azithromycin, 1 g in a single dose, or doxycycline, 100 mg twice daily for 7 days, is effective. Alternative treatments erythromycin, 500 mg 4 times daily for 7 days, or ofloxacin, 300 mg twice daily for 7 days. Patient's sexual partner should also be evaluated and treated. Doxycycline should not be used in children younger than 9 years of age. Ofloxacin should be used with caution in those...
Causes of Neutropenia in Children
Most common cause of transient neutropenia in childhood typically lasts 3 days to 1 week. Causes include hepatitis A and B, parvovirus, respiratory syncytial, Epstein-Barr, cytomegalovirus, HIV, influenza A and B, and varicella viruses. 2. Benign ethnic neutropenia. Racial variation is seen in normal WBC counts. For children aged 2 weeks to 1 year, the lower limit of normal is 1000 mm3 for white infants and 500 mm3 for black infants. Similarly, for white and black children older than 1...
Vaginitis or Vulvitis
Common cause of vaginitis in prepubertal girls. Presents with serous discharge, marked erythema and irritation of the vulvar area, and discomfort on walking and urination. 2. Candida. Can also cause vaginitis but typically causes intense pruritus. Labia may be pale or erythematous with satellite lesions. Vaginal discharge, if present, is usually thick and adherent, with white curds. 3. Other causes. In sexually active adolescents, the most common causes include bacterial...
