Evaluation of the Sick Child in the Office and Clinic

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Chapter 60 Evaluation of the Sick Child in the Office and Clinic

Acutely ill children pose a challenge to a busy pediatrician’s office. Illnesses can span the spectrum from simple viral infections to life-threatening emergencies. Pediatricians need to distinguish between patients who can be managed with close follow-up and those that need to be stabilized and transported to a higher level of care. Although patients of all ages can present with similar symptoms, the etiology of the illness can be age-dependent. The initial approach must focus on the general evaluation and stabilization of the acutely ill infant and child.

History

A thorough history is paramount to arriving at the correct diagnosis. In younger patients, parents must interpret how their child is “feeling.” Older children may not be able to completely define or localize their symptoms. On the basis of the chief complaint, the pediatrician must ask questions that help distinguish between common and potentially life-threatening entities. Common complaints leading to acute care visits include altered mental status, vomiting, respiratory distress, fever, and abdominal pain.

For patients presenting with altered mental status, the pediatrician should inquire about the presence of other symptoms such as fever or headache. Screening questions regarding feeding changes, medications in the household, or the possibility of trauma should be asked. Parents will often describe a febrile child as “lethargic,” but further questioning will reveal a tired appearing child who interacts appropriately when he or she has defervesced. Febrile patients need to be differentiated from the lethargic child who presents with sepsis or meningitis. Infants with meningitis or sepsis may have a history of irritability and/or inconsolability, not waking up for feedings, poor feeding, grunting respirations, seizures, and decreased urine output. Patients with poisonings or inborn errors of metabolism can also present with lethargy, poor feeding, seizures, and vomiting. Nonaccidental trauma should always be considered in a lethargic infant. Older children may present with altered mental status due to meningitis/encephalitis, trauma, or ingestions. Children with meningitis may have a history of fever and complaints of neck pain; other associated symptoms can include photophobia and vomiting. Children with ingestions can present with other abnormal neurologic symptoms such as ataxia, slurred speech, seizures, or characteristic constellations of vital sign changes and other physical findings (toxidromes).

Vomiting is a very common complaint of intestinal, abdominal (pancreas, liver) or non-gastrointestinal (hyperammonemia, increased intracranial pressure) origin. Care should be taken to determine whether the emesis is bilious, which is suggestive of intestinal obstruction. Other historical data to be gathered include the presence of abdominal distention, weight changes, presence of diarrhea, obstipation or hematochezia, history of trauma, and presence of headache. Although common causes of vomiting are gastroesophageal reflux and viral gastroenteritis, the pediatrician needs to be aware of other serious causes. In the infant, bilious emesis and abdominal distention and/or pain are worrisome for obstruction, as may be seen with malrotation with midgut volvulus or Hirschsprung disease. It is important to consider extra-abdominal causes of vomiting in the neonate, including hydrocephalus, incarcerated hernia, inborn errors of metabolism, and nonaccidental trauma. Markedly increasing head circumference or a bulging fontanel can be the result of congenital hydrocephalus or can signal the presence of subdural hematomas from nonaccidental trauma. In an older child, the differential diagnosis includes intussusception, incarcerated hernia, diabetic ketoacidosis, appendicitis, poisonings, and trauma. Patients with intussusception may present with vomiting and colicky abdominal pain. A history of increased urination in the presence of vomiting may herald the diagnosis of diabetes mellitus. Patients with headache and vomiting raise a concern for increased intracranial pressure and should be questioned about neurologic changes, meningismus, and fever. Vomiting may be also a nonspecific symptom of a systemic illness (otitis media, sinusitis).

Parents can interpret different symptoms as respiratory distress. Tachypnea secondary to fever is quite concerning. Parents of newborn infants are sometimes alarmed by the presence of periodic breathing. Normal variations in respiratory patterns must be distinguished from true respiratory distress. Parents need to be questioned regarding associated symptoms such as fever, limitation of neck movement, drooling, choking, and the presence of stridor or wheezing. A history of apnea or cyanosis warrants further investigation. Although wheezing is often secondary to bronchospasm, it can also be caused by cardiac disease or congenital anomalies such as vascular rings. Infants with congenital heart defects may be tachypneic but may lack any signs of respiratory distress as a compensatory mechanism for shock or metabolic acidosis. Older children who present with wheezing after a coughing or choking episode should be evaluated for a foreign body aspiration. Stridor is most commonly due to croup. However, anatomic abnormalities such as laryngeal webs, laryngomalacia, subglottic stenosis, and paralyzed vocal cords also cause stridor. In toxic-appearing children with respiratory distress, the pediatrician should entertain the possibilities of epiglottitis, bacterial tracheitis, or a rapidly expanding retropharyngeal abscess. The incidence of epiglottitis has markedly declined with the advent of the Haemophilus influenzae type b (Hib) vaccine, but remains a possibility in the unimmunized or partially immunized patient. Children with retropharyngeal abscesses may present with drooling and limitation of neck movement, especially hyperextension.

Fever is the most common reason for a sick child visit. Most fevers are the result of self-limited viral infections. However, pediatricians need to be aware of the age-dependent potential for serious bacterial infections (urinary tract infections, sepsis, meningitis, dysentery, osteoarticular infection). During the first 3 mo of life, the neonate is at risk for sepsis due to pathogens that are uncommon in older children. These organisms include group B streptococcus, Escherichia coli, Listeria monocytogenes, and herpes simplex virus. In neonates, the history must include maternal obstetric information and the patient’s birth history. Risk factors for sepsis include maternal group B streptococcus colonization, prematurity, chorioamnionitis, and prolonged rupture of membranes. If there is a maternal history of sexually transmitted infections during the pregnancy, the differential diagnosis must be expanded to include those pathogens. Septic infants can present with lethargy, poor feeding, grunting respirations, and impaired perfusion, in addition to fever. Infants with fever, irritability, and a bulging fontanel should be evaluated for meningitis. As the infant matures beyond 3 mo of age, the bacterial pathogens that usually cause bacteremia, sepsis, and meningitis are Streptococcus pneumoniae, H. influenzae type b (if the child is unimmunized or only partially immunized), and Neisseria meningitidis. Immunization against some serotypes of S. pneumoniae appears to be reducing the occurrence of occult bacteremia and serious infections caused by that organism, as has immunization against H. influenzae type b. Other ailments that manifest with fever include septic arthritis and osteomyelitis, juvenile rheumatoid arthritis, and Kawasaki disease. Children with a septic joint generally present with only one joint that is painful and often have pseudoparalysis of that joint. In contrast, patients with juvenile rheumatoid arthritis may present with pain, stiffness, swelling, and warmth of several joints. The diagnosis of Kawasaki disease should be considered if the patient meets the diagnostic criteria for this illness (Chapter 160).

Abdominal pain