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CASE FILES
Pediatrics
• The leading medical case- based series
• 60 realistic patient vignettes with open- ended questions
to sharpen your clinical problem- solving skills
• USMLE- style questions, clinical pearls, and review

questions to enhance learning
• Learning system proven to help you excel in the

clinical settings and ace your exams
TOY • HORMANN YETMAN • McNEESE

LAHOTI • OMORUYI • GELTEMEYER
LANGE
SIXTH EDITION
CASE FILES®
Pediatrics
Eugene C. Toy, MD McGovern Medical School at The University
Assistant Dean for Educational Programs of Texas Health Science Center at Houston
Director of Doctoring Courses (UTHealth)
Professor and Vice Chair of Medical Education Houston, Texas
Department of Obstetrics and Gynecology Sheela L. Lahoti, MD
McGovern Medical School at The University Professor of Pediatrics
of Texas Health Science Center at Houston Associate Dean for Admissions and Student Affairs
(UTHealth) Division of Child Safety and Integrated Care
Houston, Texas
Department of Pediatrics
Mark D. Hormann, MD McGovern Medical School at The University
Professor of Pediatrics of Texas Health Science Center at Houston
Vice Chair for Education and Training (UTHealth)
Division of Community and General Pediatrics Houston, Texas
McGovern Medical School at The University Emma A. Omoruyi, MD, MPH
of Texas Health Science Center at Houston Associate Professor of Pediatrics
(UTHealth) Division of Community and General Pediatrics
Houston, Texas Department of Pediatrics
Robert J. Yetman, MD McGovern Medical School at The University
Professor of Pediatrics of Texas Health Science Center at Houston
Vice Chair for Clinical Operations (UTHealth)
Director, Division of Community and Houston, Texas
General Pediatrics Abby M. Geltemeyer, MD
Department of Pediatrics Assistant Professor of Pediatrics
McGovern Medical School at The University Division of Community and General Pediatrics
of Texas Health Science Center at Houston Department of Pediatrics
(UTHealth) McGovern Medical School at The University
Houston, Texas of Texas Health Science Center at Houston
Margaret C. McNeese, MD (UTHealth)
Ransom Lummis Family Professor of Pediatrics Houston, Texas
Vice Dean for Admissions and Student Affairs
Division of Community and General Pediatrics
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
00_Toy-Pediatrics_FM_p000i-xxiv.indd 1 23/07/21 6:34 PM

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DEDICATION
To pediatricians everywhere, who are well known as “the nicest doctors”,

and especially to my pediatrician Dr. Patrick Robert Robbie at Kaiser Sunset
in Los Angeles, who passed away in 2013. Dr. Robbie’s gentle manner, expertise,
and sense of humor made such an impression on me as
“the kindest and smartest person I had ever encountered”,
made each patient feel special, and inspired me to pursue medicine.
—Eugene C. Toy

CONTENTS
Reviewers / vii
Contributors / ix
Preface / xv
Acknowledgments / xvii
Introduction / xix
Listing of Cases / xxi
Section I
How to Approach Clinical Problems....................................................................1
Part 1. Approach to the Patient.................................................................................................. 3
Part 2. Approach to Clinical Problem Solving....................................................................... 9
Part 3. Approach to Reading.....................................................................................................11
Section II
Clinical Cases.......................................................................................................15
Sixty Case Scenarios.....................................................................................................................17
Section III
Review Questions ...................................................................................................................... 567
Index / 601

REVIEWERS
Heba A. Ahmad, MS4

Medical Student
McGovern Medical School at the University of Texas Houston
Health Science Center at Houston (UTHealth)
Houston, Texas
Manuscript Reviewer
Joy M. Davis, MS4
Medical Student
Houston, Texas
Manuscript Reviewer
Allison L. Toy, RN
Waco, Texas
Senior Medical Writer
Principal Manuscript Reviewer
vii

CONTRIBUTORS
Kristopher Ahn, MD
Internal Medicine-Pediatrics Resident
Houston, Texas
Patent Ductus Arteriosus
Mohammad Alnoor, MD
Pediatric Cardiology Fellow
Doernbecher Children’s Hospital
Portland, Oregon
Bacterial Enteritis
Craig Authenment, MD
Pediatric Resident
Houston, Texas
Acute Otitis Media
Adolescent Substance Use Disorder
Diabetic Ketoacidosis
Andrea Carlo-Angleró, MD
Pediatric Resident
Houston, Texas
Atopic and Contact Dermatitis
Attention Deficit Hyperactivity Disorder
Immunodeficiency and Human Immunodeficiency Virus
Cathy Chang, MD
Pediatric Hospitalist
Texas Children’s Hospital
Houston, Texas
Cystic Fibrosis
Wan-Hsuan Chen, DO
Memorial Hermann Hospital Sugar Land
Sugar Land, Texas
Inflammatory Bowel Disease
Subdural Hematoma
Sudden Infant Death Syndrome
ix

x CONTRIBUTORS
R. William Chong, MD
Houston, Texas
Neonatal Hyperbilirubinemia
Nursemaid’s Elbow (Subluxation of Radial Head)
Slipped Femoral Capital Epiphysis
Emily Hopkins, MD
Pediatric Chief Resident
Houston, Texas
Trisomy 21
Julie Hwang, DO
Wise Health System
Decatur, Texas
Stevens-Johnson Syndrome
Jill Jacoby, MD
Houston, Texas
Anemia in the Pediatric Patient
Tarun Jain, MD
Houston, Texas
Pneumonia and Tuberculosis
Precocious Puberty
Retropharyngeal Abscess
Monica Kodakandla, MD
Memorial Hermann Hospital Memorial City
Houston, Texas
Transient Tachypnea of the Newborn
Patent Ductus Arteriosus
Charlyn Laserna, MD
Neonatal Hospitalist
Mount Sinai West Hospital
New York, New York
Turner Syndrome

CONTRIBUTORS xi
Ryan Le, MD
Houston, Texas
Pediatric Eye Problems
Child Abuse
Esophageal Atresia
Jeffrey Lofgran, MD
Internal Medicine-Pediatrics Hospitalist
Utah Valley and American Fork Hospitals
Provo, Utah
Measles
Jason Meschin, MD
Pediatric Resident
Houston, Texas
Epstein-Barr Virus (Infectious Mononucleosis)
Meningitis
Truncus Arteriosus
Shilpa Mohan, MD
Pediatric Nephrology Fellow
UCLA Mattel Children’s Hospital
Los Angeles, California
Postinfectious Glomerulonephritis
Posterior Urethral Valves
Rickets
Fernando Najar, DO
Neonatal-Perinatal Fellow
Baylor Scott and White Medical Center
Temple, Texas
Obstructive Sleep Apnea Syndrome
Nicolas A. Ortiz, MD
Pediatric Cardiology Fellow
Nicklaus Children’s Hospital
Miami, Florida
Failure to Thrive
Sepsis and Group B Streptococcal Infections
Growth Hormone Deficiency

xii CONTRIBUTORS
Tuong Phan, MD
Houston, Texas
Febrile Seizures
Lead Ingestion
Neonatal Herpes Simplex Virus Infection
Syeda Hiba Rizvi, MD
Pediatric Resident
McGovern Medical School at the University of Texas
Houston Health Science Center at Houston (UTHealth)
Houston, Texas
Pelvic Inflammatory Disease
Mauro Rodriguez, DO
Pediatric Resident
Houston, Texas
Appendicitis
Asthma Exacerbation
Concussion
Carly Rosemore, MD
Pediatric Hematology/Oncology Fellow
Memorial Sloan Kettering Cancer Center
New York, New York
Acute Lymphoblastic Leukemia
Immune Thrombocytopenic Purpura
Neuroblastoma
Zeina Saleh, MD
Pediatric Resident
Houston, Texas
Anaphylactoid Purpura
Ekta Shah, DO
Child Neurology Resident
Houston, Texas
Myasthenia Gravis

CONTRIBUTORS xiii
Irtiza Sheikh, DO
Pediatric Hematology/Oncology Fellow
University of Texas MD Anderson Cancer Center
Houston, Texas
Infant of a Diabetic Mother
Kawasaki Disease
Rectal Bleeding
Karli Silverberg, MD
Pediatric Resident
Houston, Texas
Accidental Drug Ingestion
Leigh Anna Stubbs, MD, MDH
Pediatric Rheumatology Fellow
Texas Children’s Hospital
Houston, Texas
Juvenile Idiopathic Arthritis
Systemic Lupus Erythematosus
Brian Townsend, DO
Private Pediatrician
Blue Fish Pediatrics
Cypress, Texas
Infant Rashes
Sophia Wang, MD
Pediatric Urgent Care Fellow
Children’s National
Washington, DC
Headache in Children
Intestinal Malrotation
Muscular Dystrophy
Sarah Lund Wilson, MD
Child Neurology Resident
McGovern Medical School at the University of Texas
Houston Health Science Center at Houston (UTHealth)
Houston, Texas
Myasthenia Gravis
Regina Yu, DO
Pediatric Critical Care Fellow
Harbor-UCLA Medical Center
Los Angeles, California
Sickle Cell Disease

PREFACE
We appreciate all the kind remarks and suggestions from the many medical
students over the past 3 years. Your positive reception has been an incredible
encouragement since the inception of the Case Files® series. In this sixth edition
of Case Files®: Pediatrics, the basic format of the book has been retained. Improve-
ments were made in updating many of the sections, including grouping of the cases
in a more logical order for students to more easily cross-reference cases. We have
also used case correlations to assist further. We reviewed the clinical scenarios and
revised several of them, keeping their “real-life” presentations patterned after actual
clinical experience. We have written seven new cases, including Infant Rashes,
Accidental Drug Ingestion, Anemia in the Pediatric Patient, Pelvic Inflammatory
Disease, Patent Ductus Arteriosus, Myasthenia Gravis, and Juvenile Idiopathic
Arthritis. We have used a bulleted format for the summary for easier reading and
correlated entrustable professional activities (EPAs) for the learning objectives. The
multiple-choice questions have been carefully reviewed and rewritten to ensure that
they comply with the National Board and USMLE format, and the Review Ques-
tions (Section III) have been updated for the student to test their knowledge after
reading the book. Through this sixth edition, we hope that the reader will continue
to enjoy learning how to diagnose and manage patients through the simulated clini-
cal cases. It certainly is a privilege to be teachers for so many students, and it is with
humility that we present this edition.
The Authors
xv

ACKNOWLEDGMENTS
The clerkship curriculum that evolved into the ideas for this edition was inspired
by two talented and forthright students, Philbert Yao and Chuck Rosipal, who
have since graduated from medical school. It has been a tremendous joy to work
with the excellent pediatricians at the McGovern Medical School at the University
of Texas Health Science Center (UTHealth) at Houston. I am greatly indebted
to my editor, Bob Boehringer, whose experience and vision helped to shape this
series. I appreciate McGraw Hill’s believing in the concept of teaching through
clinical cases, and I would like to especially acknowledge Catherine Saggese for
her production expertise, Madison Tucky for her editorial guidance, and Revathi
Viswanathan for her excellent production skills. At the McGovern Medical School
at Houston, I appreciate Dr. Barbara Stoll, our recently retired Dean, for her sup-
port. Without the encouragement from my chairman Dr. Sean Blackwell, a won-
derful clinician, administrator, scientist, and leader, and Dr. Patricia Butler, Vice
Dean for Educational Programs, who inspires us all to be excellent educators, I
could not have succeeded in this endeavor. Two medical students—Joy Davis and
Heba Ahmad—were instrumental in providing excellent feedback and recommen-
dations. I continue to marvel at my daughter Allison’s amazing intellectual, clinical,
and writing ability, effortlessly elevating the quality of our Case Files manuscripts.
Most of all, I appreciate my ever-loving wife Terri, and my four wonderful children
Andy and his wife Anna, Michael and his wife Nadine, Allison, and Christina and
her husband Andy, for their patience and understanding in the writing process.
Eugene C. Toy, MD
xvii

INTRODUCTION
Mastering the cognitive knowledge within a field such as pediatrics is a formidable

task. It is even more difficult to draw on that knowledge, procure and filter through
the clinical and laboratory data, develop a differential diagnosis, and finally form
a rational treatment plan. To gain these skills, the student often learns best at the
bedside, guided and instructed by experienced teachers, and inspired toward self-
directed, diligent reading. Clearly, there is no replacement for education at the bed-
side. Unfortunately, clinical situations usually do not encompass the breadth of the
specialty. Perhaps the best alternative is a carefully crafted patient case designed to
stimulate the clinical approach and decision making. In an attempt to achieve that
goal, we have constructed a collection of clinical vignettes to teach diagnostic or
therapeutic approaches relevant to pediatrics. Most importantly, the explanations
for the cases emphasize the mechanisms and underlying principles, rather than
merely rote questions and answers. This book is organized for versatility. It allows
the student “in a rush” to go quickly through the scenarios and check the corre-
sponding answers, while allowing the student who wants more thought-provoking
explanations to go at a more measured pace. The answers are arranged from simple
to complex: a summary of the pertinent points, the bare answers, an analysis of the
case, an approach to the topic, comprehension questions at the end for reinforce-
ment and emphasis, and a list of references for further reading. A listing of cases
is included in Section III to aid the student who desires to test his or her knowl-
edge of a specific area or who wants to review a topic. Finally, we intentionally did
not primarily use a multiple-choice question format in our clinical case scenarios
because clues (or distractions) are not available in the real world. Nevertheless, sev-
eral multiple-choice comprehension questions are included at the end of each case
discussion to reinforce concepts or introduce related topics.
HOW TO GET THE MOST OUT OF THIS BOOK

Each case is designed to simulate a patient encounter with open-ended questions.
At times, the patient’s complaint is different from the most concerning issue, and
sometimes extraneous information is given. The answers are organized into four
different parts:
PART I
1. Summary: The salient aspects of the case are identified, filtering out the extraneous
information. Students should formulate their summary from the case before looking
at the answers. These are now in bulleted form for easier reading. A comparison to the
summation in the answer will help to improve their ability to focus on the important
data while appropriately discarding the irrelevant information—a fundamental skill in
clinical problem solving.
2. A straightforward Answer is given to each open-ended question.
xix

xx INTRODUC TION
Table 1 • SYNOPSIS OF ENTRUSTABLE PROFESSIONAL ACTIVITIES

EPA 1 Gather a history and perform a physical examination
EPA 2 Prioritize a differential diagnosis following a clinical encounter
EPA 3 Recommend and interpret common diagnostic and screening tests
EPA 4 Enter and discuss orders and prescriptions
EPA 5 Document a clinical encounter in the patient record
EPA 6 Provide an oral presentation of a clinical encounter
EPA 7 Form clinical questions and retrieve evidence to advance patient care
EPA 8 Give or receive a patient handover to transition care responsibly
EPA 9 Collaborate as a member of a interprofessional team
EPA 10 Recognize a patient requiring urgent or emergent care and initiate evaluation
and management
EPA 11 Obtain informed consent for tests and/or procedures
EPA 12 Perform general procedures as a physician
EPA 13 Identify system failures and contribute to a culture of safety and improvement
3. The Analysis of the case is composed of two parts:

a. Objectives: A listing of the main principles that are crucial for a practitioner to
manage the patient. Again, the students are challenged to make educated “guesses”
about the objectives of the case upon initial review of the case scenario, which
helps to sharpen their clinical and analytical skills. The objectives are linked to the
entrustable professional activities (EPAs), which are listed in Table 1.
b. Considerations: A discussion of the relevant points and brief approach to the spe-
cific patient.
PART II
Approach to the disease process consists of two distinct parts:
a. Definitions: Terminology pertinent to the disease process.
b. Clinical Approach: A discussion of the approach to the clinical problem in general,
including tables, figures, and algorithms.
PART III
Comprehension Questions: Each case contains several multiple-choice questions, which
reinforce the material or introduce new and related concepts. Questions about material
not found in the text have explanations in the answers.
PART IV
Clinical Pearls: Several clinically important points are reiterated as a summation of the
text. This allows for easy review, such as before an examination.

LISTING OF CASES
LISTING BY CASE NUMBER

CASE NO. DISEASE CASE PAGE
1 Infant Rashes 17
2 Infant of a Diabetic Mother 27
3 Neonatal Hyperbilirubinemia 35
4 Sepsis and Group B Streptococcal Infections 45
5 Accidental Drug Ingestion 55
6 Neonatal Herpes Simplex Virus Infection 61
7 Esophageal Atresia 71
8 Transient Tachypnea of the Newborn 79
9 Pediatric Eye Problems 87
10 Failure to Thrive 97
11 Anemia in the Pediatric Patient 107
12 Rickets 117
13 Sickle Cell Disease With Vaso-Occlusive Crisis 129
14 Pneumonia and Tuberculosis 139
15 Rectal Bleeding 151
16 Acute Otitis Media 159
17 Pelvic Inflammatory Disease 169
18 Cystic Fibrosis 177
19 Acute Lymphoblastic Leukemia 185
20 Asthma Exacerbation 193
21 Sudden Infant Death Syndrome 203
22 Patent Ductus Arteriosus 211
23 Cyanotic Congenital Heart Disease 219
24 Measles 229
25 Lead Ingestion 237
26 Stevens-Johnson Syndrome 247
27 Bacterial Meningitis 257
28 Bacterial Enteritis 265
29 Subdural Hematoma 273
30 Febrile Seizures 283
31 Muscular Dystrophy 291
32 Atopic Dermatitis and Contact Dermatitis 299
33 Neuroblastoma 311
34 Intestinal Malrotation 319
35 Posterior Urethral Valves 327
xxi

xxii LISTING OF CASES
36 Nursemaid’s Elbow (Radial Head Subluxation) 335

37 Immune Thrombocytopenic Purpura 343
38 Child Abuse 351
39 Kawasaki Disease 359
40 Immunodeficiency and Human Immunodeficiency Virus 369
41 Trisomy 21 379
42 Diabetic Ketoacidosis 387
43 Obstructive Sleep Apnea Syndrome 395
44 Growth Hormone Deficiency 403
45 Precocious Puberty 413
46 Retropharyngeal Abscess 425
47 Slipped Capital Femoral Epiphysis 435
48 Headache in Children 445
49 Adolescent Substance Use Disorder 455
50 Turner Syndrome 471
51 Systemic Lupus Erythematosus 479
52 Acute Postinfectious Glomerulonephritis 489
53 Inflammatory Bowel Disease 497
54 Appendicitis 505
55 Acute Epstein-Barr Virus
(Infectious Mononucleosis) 515
56 Myasthenia Gravis 523
57 Juvenile Idiopathic Arthritis 533
58 Anaphylactoid Purpura 543
59 Attention Deficit Hyperactivity Disorder 551
60 Concussion 559
LISTING BY DISORDER (ALPHABETICAL)

CASE NO. DISEASE CASE PAGE
5 Accidental Drug Ingestion 55

55 Acute Epstein-Barr Virus
(Infectious Mononucleosis) 515
19 Acute Lymphoblastic Leukemia 185
16 Acute Otitis Media 159
52 Acute Postinfectious Glomerulonephritis 489
49 Adolescent Substance Use Disorder 455
58 Anaphylactoid Purpura 543
11 Anemia in the Pediatric Patient 107
54 Appendicitis 505
20 Asthma Exacerbation 193

LISTING OF CASES xxiii
32 Atopic Dermatitis and Contact Dermatitis 299

59 Attention Deficit Hyperactivity Disorder 551
28 Bacterial Enteritis 265
27 Bacterial Meningitis 257
38 Child Abuse 351
60 Concussion 559
23 Cyanotic Congenital Heart Disease 219
18 Cystic Fibrosis 177
42 Diabetic Ketoacidosis 387
7 Esophageal Atresia 71
10 Failure to Thrive 97
30 Febrile Seizures 283
44 Growth Hormone Deficiency 403
48 Headache in Children 445
37 Immune Thrombocytopenic Purpura 343
40 Immunodeficiency and Human Immunodeficiency Virus 369
2 Infant of a Diabetic Mother 27
1 Infant Rashes 17
53 Inflammatory Bowel Disease 497
34 Intestinal Malrotation 319
57 Juvenile Idiopathic Arthritis 533
39 Kawasaki Disease 359
25 Lead Ingestion 237
24 Measles 229
31 Muscular Dystrophy 291
56 Myasthenia Gravis 523
33 Neuroblastoma 311
6 Neonatal Herpes Simplex Virus Infection 61
3 Neonatal Hyperbilirubinemia 35
36 Nursemaid’s Elbow (Radial Head Subluxation) 335
43 Obstructive Sleep Apnea Syndrome 395
22 Patent Ductus Arteriosus 211
9 Pediatric Eye Problems 87
17 Pelvic Inflammatory Disease 169
14 Pneumonia and Tuberculosis 139
35 Posterior Urethral Valves 327
45 Precocious Puberty 413
15 Rectal Bleeding 151
46 Retropharyngeal Abscess 425
12 Rickets 117
4 Sepsis and Group B Streptococcal Infections 45
13 Sickle Cell Disease With Vaso-Occlusive Crisis 129
47 Slipped Capital Femoral Epiphysis 435

xxiv LISTING OF CASES
26 Stevens-Johnson Syndrome 247

29 Subdural Hematoma 273
21 Sudden Infant Death Syndrome 203
51 Systemic Lupus Erythematosus 479
8 Transient Tachypnea of the Newborn 79
41 Trisomy 21 379
50 Turner Syndrome 471

SECTION I
How to Approach
Clinical Problems
Part 1 Approach to the Patient

Part 2 Approach to Clinical Problem Solving
Part 3 Approach to Reading
01_Toy-Pediatrics_Sec01_p001-014.indd 1 10/03/21 8:22 AM

SECTION I: HOW TO APPROACH CLINICAL PROBLEMS 3
Part 1. Approach to the Patient

The transition of information from the textbook or journal article to the clinical
situation is perhaps the most challenging in medicine. Retention of information is
difficult; organization of the facts and recall of myriad data to apply to the patient
are crucial. This text aids in the process. The first step is gathering information,
otherwise known as establishing the database. This consists of taking the history
(asking questions), performing the physical examination, and obtaining selective
laboratory and/or imaging tests.
The history is the single most important method of establishing a diagnosis.
Depending on the age of the child, the information may be gathered solely from
the parent, from both the parent and the child, or solely from the adolescent. The
student should remember not to be misled by the diagnosis of another clinician
or by a family member. A statement such as “Johnnie has pneumonia and needs
antibiotics” may or may not be correct; an astute clinician will keep an open mind
and consider other possibilities, such as upper respiratory tract infection, aspi-
rated foreign body, reactive airway disease, or even cystic fibrosis. The art of seek-
ing the information in a nonjudgmental, sensitive, and thorough method cannot
be overemphasized.
HISTORY
1. Basic information:
a. Age, gender, and ethnicity are important because some childhood illnesses
occur with increased regularity at various ages, with higher frequency in
one gender or more commonly in one ethnic group. For instance, anorexia
nervosa is more common in White adolescent females, whereas complica-
tions of sickle cell anemia are more common in African American children
of both genders.
2. Chief complaint: This is usually the response that the patient or the patient’s
family member gives to the question: “Why are you seeing the doctor today?”
3. History of present illness: The onset, duration, and intensity of the primary
complaint, as well as associated symptoms, exacerbating and relieving factors,
and previous attempts at therapy, should be determined. For children, espe-
cially adolescents, a hidden agenda must be considered; it is not uncommon
for the adolescent to actually have questions about sexuality when the stated rea-
son for the office visit is totally unrelated. Both positive findings (the stool was
loose, voluminous, and foul smelling) and negative findings (without blood or
mucus) are appropriate.
4. Past history:
a. Pregnancy and delivery: The age of the mother, the number of pregnancies,
the route of delivery, and the gestational age of the infant often can provide
clues as to the etiology of pediatric conditions. For instance, a large, full-term
infant born by cesarean delivery who then develops an increased respiratory

4 CASE FILES: PEDIATRICS
rate and streakiness on a chest radiograph is more likely to have transient

tachypnea of the newborn than is an infant born vaginally at 28 weeks’ gesta-
tion with similar symptoms where a diagnosis of surfactant deficiency is the
more likely cause of respiratory symptoms. A history of drug use (including
over-the-counter, prescription, and illicit drugs) or infections during preg-
nancy should also be obtained.
b. Neonatal history: Any problems identified in the neonatal period, such as
severe jaundice, infections, feeding difficulties, and prolonged hospitaliza-
tion, should be reviewed, especially for the younger pediatric patients in
whom residua of these problems may remain.
c. Surgical history: When, where, and for what reason the surgery was per-
formed should be explored. Complications should be noted.
d. Medical history: Whereas minor illnesses (such as occasional upper respi-
ratory infections) can be reviewed quickly, more serious illnesses (such as
diabetes mellitus) should be investigated fully. The age at diagnosis, treat-
ments prescribed, and response to therapies can be reviewed. The number
and nature of hospitalizations and complications are often important. For
instance, a diabetic patient with frequent hospitalizations for ketoacidosis
may indicate a lack of education of the family or underlying psychosocial
issues complicating therapy. A child with a history of frequent, serious acci-
dents should alert the health care provider of possible child abuse.
e. Developmental history: For preschool children, a few questions about lan-
guage and fine motor, gross motor, and psychosocial skills will provide good
clues about development. For school-aged children, school performance
(grades) and areas of strength and weaknesses are helpful.
5. Allergies: Reactions to medications should be recorded, including severity and
temporal relationship to medications.
6. Immunizations: Dates for primary and booster series of immunizations should
be recorded, preferably by reviewing the immunization cards or accessing the
state’s immunization registry. If the child is in school, a presumption about
state laws regarding immunization completion can be made while the immuni-
zation card is being retrieved.
7. Medications: List the names of current medications, dosages, routes of admin-
istration and frequency, and durations of use. Prescription, over-the-counter,
and herbal remedies are relevant.
8. Sexual history of adolescents: Details of an adolescent’s sexual habits, con-
traceptive use, pregnancies, and sexually transmitted infections should be
determined.
CLINICAL PEARL
»» The adolescent must be treated with sensitivity, respect, and confidenti-
ality to foster the optimal environment for medical care.

9. Family history: Because many conditions are inherited, the ages and health of
siblings, parents, grandparents, and other family members can provide impor-
tant diagnostic clues. For instance, an obese child with a family history of
adult-onset diabetes is at high risk for developing diabetes; early intervention
is warranted.
10. Social history: Living arrangements, economic situations, types of insurance,
and religious affiliations may provide important clues to a puzzling diagnostic
case or suggest important information about the acceptability of therapeutic
options.
11. Review of systems: A few questions about each of the major body systems
allows the practitioner to ensure that no problems are overlooked and to
obtain crucial history about related and unrelated medical conditions.
PHYSICAL EXAMINATION
1. General appearance: Well versus poorly nourished; evidence of toxemia, includ-
ing lethargy (defined as poor or absent eye contact and refusal to interact with
environment), signs of poor perfusion, hypo- or hyperventilation, and cyano-
sis; or stigmata of syndromes (such as Down or Turner).
2. Skin: In smaller children, checking the color of the skin for evidence of pallor,
plethora, jaundice, or cyanosis is important. Abnormalities such as capillary
hemangiomas (eg, “stork bites” in a newborn), café-au-lait spots, pigmented
nevi (eg, congenital dermal melanocytosis [also known as “Mongolian
spots”]), erythema toxicum, or pustular melanosis can be identified. In
older children, macules, papules, vesicles, pustules, wheals, and petechiae or
purpura should be described, and evidence of excoriation, crust formation,
desquamation, hyperpigmentation, ulceration, scar formation, or atrophy
should be identified.
3. Vital signs: Temperature, blood pressure (generally begin routine measure-
ment after 3 years), heart rate, respiratory rate, height, weight, and head cir-
cumference (generally measured until age 3 years). Measurements are plotted
and compared to normals for age.
4. Head, eyes, ears, nose, mouth, and throat:
a. Head: For the neonate, the size of fontanelles and presence of overriding
sutures, caput succedaneum (superficial edema or hematoma that crosses
suture lines, usually located over crown), or cephalohematoma (hematoma
that does not cross suture lines) should be noted. For the older child, the
size and shape of the head as well as abnormalities such as swellings, depres-
sions, or abnormal hair quality or distribution may be identified.
b. Eyes: For infants, abnormalities in the size, shape, and position of the orbits,
the color of the sclerae (blue sclerae, for instance, may indicate osteogenesis
imperfecta), conjunctival hemorrhages, or the presence of iris defects (such
as coloboma) may be found. The visual acuity of older children should be
determined.

c. Ears: For all children, abnormalities in the size, shape, and position of the
ears can provide important diagnostic clues. Whereas tympanic membranes
are difficult to assess in newborns, their integrity should be assessed in
older children. For all children, the quality and character of discharge from
the ear canal should be documented.
d. Nose: The size, shape, and position of the nose (in relation to the face and
mouth) can provide diagnostic clues for various syndromes, such as a small
nose in Down syndrome. Patency of the nostrils, especially in neonates who
are obligate nose breathers, is imperative. Abnormalities of the nasal bridge
or septum, integrity of the mucosa, and the presence of foreign bodies
should be noted. A butterfly rash across the nasal bridge can be associated
with systemic lupus erythematosus (SLE), and a transverse crease across
the anterior portion of the nose is seen with allergic rhinitis.
e. Mouth and throat: The size, shape, and position of the mouth and lips in
relation to other facial structures should be evaluated. In infants, common
findings of the mouth include disruption of the palate (cleft palate syn-
drome), Epstein pearls (a tiny white papule in the center of the palate), and
short frenulum (“tongue-tied”). For all children, the size, shape, and posi-
tion of the tongue and uvula must be considered. The number and quality
of teeth for age should be assessed, and the buccal mucosa and pharynx
should be examined for color, rashes, exudate, size of tonsils, and symmetry.
5. Neck: The neck in infants usually is short and sometimes hard to evaluate.
Nonetheless, the size, shape, and preferred position of the neck can be evalu-
ated for all children. The range of motion can be evaluated by gentle move-
ment. Symmetry of the muscles, thyroid gland, veins, and arteries is important.
An abnormal mass, such as a thyroglossal duct cyst (midline above the level of
the thyroid) or brachial cleft cyst (along the sternomastoid muscle), or unusual
findings, such as webbing in Turner syndrome, can be identified.
6. Chest: General examination of the chest should include an evaluation of the
size and shape of the structures along with identification of obvious abnormal-
ities (such as supernumerary nipples) or movement with respirations. Respira-
tory rate varies according to age and ranges from 40 to 60 breaths per minute
in the neonate to 12 to 14 breaths per minute in the toddler. The degree of
respiratory distress can be stratified, with increasing distress noted when the
child moves from subcostal to intercostal to supraclavicular to suprasternal
retractions. Palpation of the chest should confirm the integrity of the ribs and
clavicles and identify any swelling or tenderness in the joints. Percussion in
older children may reveal abnormalities, especially if asymmetry is noted. The
chest should be auscultated for air movement, vocal resonance, rales, rhonchi,
wheezes, and rubs. In adolescent girls, symmetry of breast development and
presence of masses or nipple discharge should be evaluated.
7. Cardiovascular: The precordium should be inspected for abnormal move-
ments. The chest should be palpated for the location and quality of the cardiac
impulse, as well as to determine if a thrill is present. The presence and quality

of the first and second heart sounds, including splitting with respirations,
should be noted. Murmurs, clicks, rubs, and abnormalities in the heart rate
(which vary by age) or rhythm should be identified. The peripheral perfusion,
pulses, and color should be assessed.
8. Abdominal examination: The abdomen should be inspected to determine
whether it is flat or protuberant, if masses or lesions such as striae are obvious,
or if pulsations are present. In older children, the abdomen usually is flat, but
in the neonate, a very flat abdomen (scaphoid) in conjunction with respira-
tory distress may indicate diaphragmatic hernia. The umbilicus, especially for
neonates, should be evaluated for defects, drainage, or masses; a small umbili-
cal hernia often is present and is normal. In the newborn, one umbilical vein
and two umbilical arteries are normal. In the neonate, palpation of the abdo-
men may reveal a liver edge about 2 cm below the costal margin, a spleen tip, and
using deep pressure, kidneys. In older children, these structures are not usually
palpable except in pathology. Depending on the history, other masses must be
viewed with suspicion for a variety of conditions. Bowel sounds are usually
heard throughout the abdomen except in pathology. In adolescent girls, the
lower abdomen should be palpated for uterine enlargement (pregnancy).
9. Genitalia: Examination of the male for the size and shape of the penis, tes-
ticles, and scrotum is important. The position of the urethral opening should
be assessed. In newborn girls, the labia majora usually is large and completely
encloses the labia minora; the genitalia usually is highly pigmented and swollen
with an especially prominent clitoris. A white discharge is usually present in
the first days of life, and occasionally, blood-tinged fluid is also seen. In tod-
dlers, examination of the genitalia can be challenging. Placing the toddler in a
frog-leg position while the toddler sits in the parent’s lap (or on the examina-
tion table) often allows successful viewing of external genitalia. In older girls,
the knee-chest position affords an excellent view of the external genitalia. In
girls outside the newborn period, the labia minora are smaller compared to the
remainder of the external genitalia, and the vaginal mucosa is red and appears
thin. The hymen, which is just inside the introitus, should be inspected. Abnor-
malities of the hymen, such as imperforation or tags, vaginal discharge, foreign
bodies, and labial adhesions, should be noted. A speculum examination should
be performed for sexually active adolescent girls. Tanner staging for pubertal
development should be done for both boys and girls. Inguinal hernias should
be identified; normalcy of the anus should be confirmed.
10. Extremities: For all children, the size, shape, and symmetry of the extremi-
ties should be considered; muscle strength should be evaluated. Joints may be
investigated for range of motion, warmth, tenderness, and redness. Normalcy
of gait for age should be reviewed. For infants, recognition of dislocated hips
is of critical importance since lifelong growth abnormalities may result. For
adolescents, identification of significant scoliosis is important to prevent the
debilitating complications of that condition. Athletes require evaluation of the
integrity of their joints, especially those joints that will be used in sporting
activities.

11. Neurologic: Neurologic evaluation of the older child is similar to that in adults.
Consciousness level and orientation are determined as a starting point. The cra-
nial nerves should be assessed. The motor system should be evaluated (includ-
ing strength, tone, coordination, and involuntary movements). Superficial and
deep sensory systems, as well as deep tendon reflexes, should be reviewed. In
younger infants, a variety of normal primitive reflexes (Moro, parachute, suck,
grasp) can be found, and ensuring that these reflexes have extinguished by the
appropriate age is equally important.
LABORATORY ASSESSMENT
The American Academy of Pediatrics recommends a few laboratory screening
tests for pediatric patients. These tests vary according to the child’s age and risk
factors.
1. Newborn metabolic screening is done in all states, usually after 24 hours of age,
but the exact tests performed vary by state. Conditions commonly screened
for include hypothyroidism, phenylketonuria, galactosemia, hemoglobin type,
and adrenal hyperplasia. Other conditions that may be assessed include maple
syrup urine disease, homocystinuria, biotinidase deficiency, cystic fibrosis,
tyrosinemia, and toxoplasmosis. Some states require a second newborn screen
be performed after 7 days of age.
2. Measurement of oxygen saturation in all newborn infants is accomplished to
assess for critical congenital heart defects.
3. Hemoglobin or hematocrit levels are recommended for high-risk infants (espe-
cially premature infants and those with low birth weight), at about 12 months
of age, and as needed yearly if the risk of blood loss (such as in menstruating
adolescents) is high.
4. Lead screening is done, especially in high-risk areas, at 9 to 12 months of age
and again at 2 years of age.
5. Cholesterol screening is performed in high-risk patients (those with positive
family histories) older than 24 months.
6. Sexually transmitted infection screening is performed yearly on all sexually
active patients.
Other specialized testing is accomplished depending on the child’s age, risk fac-
tors, chief complaint, and conditions included in the differential diagnosis.
IMAGING PROCEDURES
1. Plain radiographs offer the advantage of inexpensive testing that reveals
global views of the anatomy. Unfortunately, fine organ detail sometimes is not
revealed and further radiographic study is required. Bone films for fracture,
chest films for pneumonia, and abdomen films for ileus are common uses of
this modality.

2. Ultrasonography is a fairly inexpensive modality that requires little or no seda-

tion and has no radiation risks. It offers good organ and anatomic detail, but it
can be operator dependent. Not all organs are accessible to sonography. Com-
mon examinations include the head for intraventricular hemorrhage (IVH) in
the premature infant, the abdomen for conditions such as pyloric stenosis or
appendicitis, and the kidneys for abnormal structure.
3. Computed tomography (CT) provides good organ and anatomic detail and is
quick, but it is fairly expensive, may require contrast, and does involve radia-
tion. Some children require sedation to complete the procedure. This test is
often performed on the abdomen or head in trauma victims.
4. Magnetic resonance imaging (MRI) is expensive but does not involve radia-
tion. Because it is a slow procedure, sedation is often needed for younger chil-
dren, and contrast is sometimes required. It allows for superb tissue contrast in
multiple planes and excellent anatomic and functional imaging. It is frequently
used to provide detail of the brain in patients with seizures or developmental
delay or to provide tissue detail on masses located virtually anywhere in the
body.
5. Nuclear scan is moderately expensive and invasive. It provides functional infor-
mation (usually organ specific) but poor anatomic detail. Radiation is involved.
Common uses include bone scans for infection and renal scans for function.
Part 2. Approach to Clinical Problem Solving

There are generally four steps to the systematic solving of clinical problems:
1. Make the diagnosis
2. Assess the severity of the disease
3. Render a treatment based on the stage of the disease
4. Follow the response to the treatment
MAKING THE DIAGNOSIS

This is achieved with careful sifting of the database, analysis based on the risk fac-
tors present, and development of a list of possibilities (the differential diagnosis).
The process includes knowing which pieces of information are more meaningful
and which can be discarded. Experience and knowledge from reading help to guide
the clinician to key in on the most important concerns. A good clinician also knows
how to ask the same question in several different ways and using different terminology
because patients at times will deny having been treated for asthma but will answer
affirmatively to being hospitalized for wheezing. A diagnosis can be reached by
systematically reviewing each possible cause and reading about each disease. The
patient’s presentation is then matched up against each of these possibilities and
either placed higher up on the list as a potential etiology or lower down because

of the disease frequency, the patient’s presentation, or other clues. A patient’s risk
factors may influence the probability of a diagnosis. Usually, a long list of possible
diagnoses can be pared down to two or three top suspicions, based on key labora-
tory or imaging tests. For example, an adolescent presenting with a fever as the
chief complaint can have an extensive differential diagnosis reduced to far fewer
possibilities when the history reveals an uncle in the home with cough that con-
tains blood, weight loss, and night sweats and the physical examination shows an
increased respiratory rate, lymphadenopathy, and right lower lobe lung crackles. In
this case, the patient likely has tuberculosis.
ASSESSING THE SEVERITY OF THE DISEASE

The next step is to characterize the severity of the disease process. In asthma, this
is done formally based on guidelines promulgated by the National Heart, Lung, and
Blood Institute (NHLBI). Asthma categories range from mild intermittent (least
severe) to severe persistent (most severe). For some conditions, such as syphilis, the
staging depends on the length of time and follows along the natural history of the
infection (ie, primary, secondary, or tertiary syphilis).
RENDERING TREATMENT BASED ON THE STAGE OF

THE DISEASE
Many illnesses are stratified according to severity because prognosis and treatment
vary based on the severity. If neither the prognosis nor the treatment is affected
by the stage of the disease process, it does not make much sense to subcatego-
rize something as mild or severe. As an example, mild intermittent asthma poses
less danger than does severe persistent asthma (particularly if the patient has been
intubated for asthma in the past). Accordingly, with mild intermittent asthma, the
management would be intermittent short-acting beta-agonist therapy while watch-
ing for any worsening of the disease into more serious categories (more severe dis-
ease). In contrast, a patient with severe persistent asthma would generally require
short-acting beta-agonist medications as well as long-acting beta-agonists, inhaled
steroids, and potentially oral steroids.
Group A beta-hemolytic streptococcal pharyngeal infection (“strep throat”)
is associated with complications including poststreptococcal glomerulonephritis
and rheumatic fever. The presence of group A beta-hemolytic Streptococcus con-
fers an increased risk of problems, but neither the prognosis nor the treatment
is affected by “more” group A beta-hemolytic Streptococcus or “less” group A beta-
hemolytic Streptococcus. Hence, the student should approach new disease by learn-
ing the mechanism, clinical presentation, how it is staged, and how the treatment
varies based on stage.
FOLLOWING THE RESPONSE TO TREATMENT

The final step in the approach to disease is to follow the patient’s response to the
therapy. Whatever the “measure” of response, it should be recorded and monitored.
Some responses are clinical, such as a change in the patient’s pain level or tempera-
ture or results of pulmonary examination. Obviously, the student must work on

being more skilled in eliciting the data in an unbiased and standardized manner.
Other patients may be followed by imaging, such as CT scan of a retroperitoneal
(RP) node size in a patient receiving chemotherapy for neuroblastoma or a marker
such as the platelet count in a patient recovering from Kawasaki syndrome. For
syphilis, it may be the nonspecific treponemal antibody test rapid plasma reagin
(RPR) titer every month. The student must know what to do if the measured
marker does not respond according to the expected. Is the next step to treat further,
or to repeat the metastatic workup, or to follow up with another more specific test?
Part 3. Approach to Reading

The student must approach reading differently than the classic “systematic” review
of a particular disease entity. Patients rarely arrive to their health care provider
with a clear diagnosis; hence, the student must become skilled in applying the text-
book information to the clinical setting. Everyone retains more when the reading is
performed with a purpose. Experience teaches that with reading, there are several
crucial questions to consider thinking clinically. They are as follows:
1. What is the most likely diagnosis?
2. What should be your next step?
3. What is the most likely mechanism for this process?
4. What are the risk factors for this condition?
5. What are the complications associated with this disease?
6. What is the best therapy?
WHAT IS THE MOST LIKELY DIAGNOSIS?

Establishing the diagnosis was discussed in the previous part. This is a difficult
task to give to the medical student; however, it is the basic problem that will con-
front clinicians for the rest of their careers. One way of attacking this problem
is to develop standard “approaches” to common clinical problems. It is helpful to
memorize the most common causes of various presentations, such as “the most
common cause of mild respiratory distress in a term infant born by cesarean section
is retained amniotic fluid (transient tachypnea of the newborn).”
The clinical scenario would entail something such as the following:
“A 3-hour-old infant is noted to have a mildly increased respiratory rate and
slight subcostal retractions. The infant is term, is large for gestational age, and was
born by repeat cesarean section. The pregnancy was uncomplicated. What is the
most likely diagnosis?”
With no other information to go on, the student would note that this baby
has respiratory distress. Using the “most common cause” information, the student
would guess transient tachypnea of the newborn. If, instead, the gestational age
“term” is changed to “preterm at 30 weeks’ gestation,” a phrase can be added, such
as the following:

“The mother did not receive prophylactic steroids prior to birth.”

Now, the student would use the “most common cause of respiratory distress in
a preterm child whose mother did not receive prenatal steroids” is surfactant defi-
ciency (respiratory distress syndrome).
WHAT SHOULD BE YOUR NEXT STEP?

In many ways, this question is even more difficult than the question about the most
likely diagnosis because there are many more possible answers. For example, insuf-
ficient information may be available to make a diagnosis and the next step may be
to pursue more diagnostic information. Another possibility is that the diagnosis is
clear, but the subsequent step is the staging of the disease. Finally, the next step may
be to treat. Hence, from clinical data, a judgment needs to be rendered regarding
how far along one is on the road of:
Make diagnosis → Stage disease → Treat based on the stage → Follow response
In particular, the student is accustomed to regurgitating the same information

that someone has written about a particular disease but is not skilled at giving the
next step. This talent is optimally learned at the bedside, in a supportive environment,
with freedom to take educated guesses, and with constructive feedback. The student
assessing a child in the hospital should go through the following thinking process:
1. Based on the information I have, I believe that Cedric Johnson (a 3-month-old
child with a positive respiratory syncytial virus nasal washing) has bronchiolitis.
2. I don’t believe that this is a severe disease (such as significant oxygen require-
ment, severe retractions, or carbon dioxide retention on blood gas analysis).
A chest radiograph shows no lobar consolidation (I believe this is important
because a lobar consolidation would suggest a bacterial etiology).
3. Therefore, the treatment is supportive care with supplemental oxygen and
intravenous fluids as needed.
4. I want to follow the treatment by assessing Cedric’s respiratory status (I will
follow the oxygen saturation and degree of retractions), his temperature, and
his ability to maintain his hydration orally without intravenous fluids. Also, if
in the next few days Cedric does not get better or if he worsens, I think he will
need a repeat chest radiograph to assess whether he has an evolving bacterial
pneumonia.
In a similar patient, when the clinical presentation is not so clear, perhaps the
best “next step” may be diagnostic in nature such as blood cultures to determine
if bacteremia is present. This information is sometimes tested by the dictum, “the
gold standard for the diagnosis and treatment of a bacterial infection is a culture.”
WHAT IS THE MOST LIKELY MECHANISM FOR THIS PROCESS?

This question goes further than requiring the student to make the diagnosis; it also
requires the student to understand the underlying mechanism for the process. For
example, a clinical scenario may describe a 5-year-old child with Henoch-Schönlein

purpura (HSP) who develops abdominal pain and heme-positive stools a week
after diagnosis. The student first must diagnose the heme-positive stools associated
with HSP, which occur in approximately 50% of patients. Then, the student must
understand that the edema and damage to the vasculature of the gastrointestinal
(GI) tract can cause bleeding along with colicky abdominal pain, sometimes pro-
gressing to intussusception. The mechanism of the pain and bleeding is, therefore,
vasculitis causing enlarged mesenteric lymph nodes, bowel edema, and hemorrhage
into the bowel. Answers that a student may speculate, but would not be as likely,
include appendicitis, bacterial gastroenteritis, or volvulus.
The student is advised to learn the mechanisms for each disease process and
not merely to memorize a constellation of symptoms. In other words, rather than
trying to commit to memory the classic presentation of HSP (typical rash, abdomi-
nal pain, and arthritis), the student should also understand that vasculitis of the
small vessels is the culprit. The vasculitis causes edema, mainly in the dependent
areas, that precedes the palpable purpura. This vasculitis is responsible not only for
edema in the joints (mainly in dependent areas such as the knees and ankles) caus-
ing the arthritis found in approximately two-thirds of patients, but also for damage
to the vasculature of the GI tract leading to the intermittent, colicky abdominal
pain that can manifest as heme-positive stools or even intussusception.
WHAT ARE THE RISK FACTORS FOR THIS CONDITION?

Understanding the risk factors helps to establish the diagnosis and interpret test
results. For example, a risk factor analysis may help to manage a 1-year-old child
with anemia found on routine screening. If the child had no risk factors for lead
poisoning or thalassemia, the practitioner may choose to treat with supplemental
iron because the likelihood for more serious pathology is low. On the other hand,
if the same 1-year-old child was a recent emigrant from an endemic area, lived in
an older home with peeling paint, had a father who worked at a battery smelting
plant, and ate meals from unglazed pottery, a practitioner should presumptively
diagnose lead poisoning until proven otherwise. The clinician may want to obtain
a serum lead level and a complete blood count with differential (looking for baso-
philic stippling and microcytosis) and thoroughly evaluate the child for develop-
mental delay. Thus, the number of risk factors helps to categorize the likelihood
of a disease process.
WHAT ARE THE COMPLICATIONS ASSOCIATED WITH

THIS DISEASE?
A clinician must understand the complications of a disease so that the patient can
be monitored. Sometimes, students will have to make the diagnosis from clinical
clues and then apply their knowledge of the sequelae of the pathologic process. For
example, a child diagnosed with high fever, rash, lymphadenopathy, and oral and
conjunctival changes is diagnosed with Kawasaki syndrome. Complications of this
condition include arthritis, vasculitis of the medium-sized arteries, hydrops of the
gallbladder, urethritis, and aseptic meningitis. Understanding the types of compli-
cations helps the clinician to assess the patient. For example, one life-threatening

complication of Kawasaki syndrome is coronary artery aneurysm and thrombosis.

The clinical presentation in the subacute phase is desquamation, thrombocytosis, and
the development of coronary aneurysms with a high risk of sudden death. The appro-
priate therapy is intravenous immunoglobulin in the acute phase and high-dose
aspirin as soon as possible after the diagnosis is made. Nonrecognition of the risk
of coronary artery aneurysm and appropriate therapy for thrombosis can lead to
the patient’s death. Students apply this information when they see on rounds a
patient with Kawasaki syndrome and monitor for new murmurs, thrombocytosis,
myocarditis, and development of coronary artery aneurysms. The clinician com-
municates to the team to watch the patient for any of these signs or symptoms so
that appropriate therapy can be considered.
WHAT IS THE BEST THERAPY?

This is perhaps the most difficult question, not only because the clinician needs
to reach the correct diagnosis and assess the severity of the condition, but also
because he or she must weigh the situation to reach the appropriate intervention.
The student does not necessarily need to memorize exact dosages, but the medica-
tion, route of delivery, and possible complications are important. It is important for
the student to verbalize the diagnosis and the rationale for the therapy. A common
error is for the student to “jump to a treatment,” almost like a random guess, and
therefore be given “right or wrong” feedback. In fact, the student’s guess may be cor-
rect but for the wrong reason; conversely, the answer may be a very reasonable one,
with only one small error in thinking. It is crucial instead to give the steps so that
feedback can be given for each step.
For example, what is the best therapy for a 15-year-old sexually active girl with
severe, cystic acne? The incorrect manner of response is for the student to blurt out
“isotretinoin (Accutane).” Rather, the student should reason it as follows:
“Severe, cystic acne can be treated with a variety of modalities. Side effects of
the medications must be considered in a sexually active teenager who is statistically
at high risk for pregnancy. Isotretinoin (Accutane) causes severe birth defects and
is absolutely contraindicated in pregnancy. Therefore, the best treatment for this
adolescent may be a combination of oral antibiotics and topical medications that
present a much lower chance of devastating side effects.”
REFERENCES
Bickley LS. Pocket Guide to Physical Examination and History Taking. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2018.
Blickman JG, Parker BR, Barnes PD. Pediatric Radiology: The Requisites. 4th ed. Philadelphia, PA: Mosby
Publishers; 2016.
Levine DA. Growth and development. In: Marcdante K, Kliegman RM, eds. Nelson Essentials of Pediatrics.
8th ed. Philadelphia, PA: Elsevier Publishers; 2018:11-28.
Zitelli BI, McIntire SC, Nowalk AJ. Pediatric Physical Diagnosis. 8th ed. Philadelphia, PA: Elsevier
Publishers; 2020.

SECTION II
Clinical Cases
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CASE 1
A 3-day-old African American male infant is seen for his early hospital follow-up
appointment. His hospital discharge summary shows that he was born via
spontaneous vaginal delivery (SVD) at 39 weeks’ gestation to a 22-year-old
gravida 1, para 0 (G1P0) mother. The pregnancy was uncomplicated, and the
mother had routine prenatal care. Maternal labs were significant for unknown
group B streptococcal (GBS) status; the mother received 2 doses of penicillin, the
last of which was 2 hours prior to delivery. Growth parameters were appropriate
for gestational age, including a weight of 3.255 kg (31%), length of 49 cm
(36%), and head circumference of 35 cm (34%). The postnatal hospital stay was
unremarkable. He was discharged on day of life 2. Since discharge, he has been
breastfeeding well and acting normally. His mother is concerned today, stating
that he has “pimples” on his body. She first noticed them on hospital day 2, but she
was told they were not a problem. She reports that some of them have “popped”
and revealed darkened skin underneath, while more have “spread” to include
his “whole body.” She reports no other problems. On examination, he is 3.10 kg
(decreased 4.8% from birth weight) and has a heart rate of 136 beats per minute,
a respiratory rate of 42 breaths per minute, and a temperature of 36.6 °C (97.8 °F).
The physical examination is normal except for the skin, which shows many
2- to 3-mm white papules, mostly on his trunk but also involving all extremities
including his palms and soles, and multiple 2- to 3-mm hyperpigmented macules
in the same distribution.
▶▶ What is the most likely diagnosis?

▶▶ What treatment would you recommend?
▶▶ What anticipatory guidance should you give the mother?

ANSWERS TO CASE 1:
Infant Rashes
Summary: A 3-day-old African American boy presents with
History of being born at term via SVD after an uneventful pregnancy
Appropriate birth growth parameters for gestational age and an unremarkable post-
natal hospital stay
Development of a pustular rash on his body on day of life 2, with unroofing of lesions
revealing hyperpigmented macules
Most likely diagnosis: Pustular melanosis.

Recommended treatment: Reassurance.
Anticipatory guidance: The rash is self-limited and will resolve on its own without
treatment. The pustular phase resolves by about 10 days of age, and the hyperpig-
mented lesions resolve by 3 to 4 months of age. The mother should not manipulate
the lesions but rather use nonirritating lotions and soaps on the infant’s skin.
ANALYSIS
Objectives
1. Recognize and be able to describe common infant rashes. (EPA 1, 2, 6)
2. Know how to manage infant rashes. (EPA 3, 4, 5, 8)
3. Know what anticipatory guidance to provide to families regarding infant
rashes. (EPA 12)
Considerations
This is a 3-day-old African American neonate born at term whose mother is con-
cerned because of a pustular rash over the body beginning on day of life 2. The
prenatal and delivery history of this child is nonconcerning. The child was born to
a GBS-positive mother, but prophylactic antibiotic therapy during labor was com-
plete. The mother has no history of herpes simplex virus (HSV), thus reducing the
chance of an infectious etiology. The infant’s postdelivery course has been normal,
suggesting a benign condition. The physical examination is normal except for the
skin showing many 2- to 3-mm white papules, mostly on his trunk but also involv-
ing all extremities including his palms and soles, and multiple 2- to 3-mm hyper-
pigmented macules in the same distribution. This is classic for pustular melanosis,
which is a benign and harmless transient skin condition of newborns. About 5% of
Black infants are affected (vs 1% of White babies). The diagnosis is made clinically.
Other conditions in the differential include HSV, miliaria (Candida), Staphylococcus
aureus infection, and pediatric erythema toxicum.

SECTION II: CLINICAL CASES 19
APPROACH TO:
Infant Rashes
DEFINITIONS
RASH: A change of the skin that affects its color, appearance, or texture.
MACULE: A distinct, flat lesion less than 1 cm.
PAPULE: A distinct, raised lesion less than 1 cm.
PATCH: A distinct, flat lesion greater than 1 cm.
PLAQUE: A distinct, raised lesion greater than 1 cm.
PUSTULE: A vesicle containing pus.
VESICLE: A fluid-filled collection less than 1 cm.
CLINICAL APPROACH
A critical component of the infant physical examination is a thorough evaluation
of the skin. A careful history including maternal and birth history precedes the
physical examination to determine whether concern for nonbenign skin lesions,
including infectious, vascular, rheumatologic, or environmental etiologies, is pres-
ent. Many infant rashes are self-limited and only require reassurance.
Erythema Toxicum
One of the most common newborn skin finding is erythema toxicum, a transient,
self-limited rash of unknown etiology that may occur in up to 50% of full-term
infants, most commonly in White infants. It is characterized by an eruption of
yellow-white papules or pustules with surrounding erythema that may occur any-
where on the body, commonly on the chest, back, and face and usually sparing the
palms and soles. Histologically, a lesion content smear shows eosinophils and no
organisms. Erythema toxicum occurs in the first 2 to 3 days of life and typically
resolves after the first week of life without intervention, and the skin then returns
to baseline pigmentation. See Figure 1–1.
Pustular Melanosis
Pustular melanosis is a transient, self-limited, multiphase process of unknown etiol-
ogy that occurs in Black infants (Figure 1–2). It is characterized by pustules in a
widespread distribution, including the palms and soles, that may be present at the
time of birth. These pustules tend to rupture and leave behind hyperpigmented mac-
ules surrounded by a “collarette” of scaly skin. Histologically, the pustules are filled
with neutrophils, no organisms are seen on Gram stain, and the hyperpigmented
macule epidermal cells demonstrate increased melanization. The pustular phase
typically lasts 2 to 3 days; the macular phase may last 3 to 4 months before resolu-
tion. No treatment is required.

Figure 1–1. Erythema toxicum. Newborn infant with diffuse macular rash of erythema toxicum.
(Reproduced with permission, from Knoop K, Stack L, Storrow A, et al. The Atlas of Emergency Medicine.
5th ed. 2021. Copyright © McGraw Hill LLC. All rights reserved. https://accessmedicine.mhmedical.com.)
Milia
Milia are 1- to 2-mm epidermal inclusion cysts that are white in color and filled
with keratin. Milia occur in up to 40% of newborns and are found concentrated
on the nose and face (Figure 1–3). Milia have intraoral counterparts called Epstein
pearls located on the palate, which are typically larger and rarely can be misidenti-
fied as natal teeth. Milia rupture spontaneously and do not require treatment.
Congenital Dermal Melanocytosis

Congenital dermal melanocytosis (CDM), formerly known as Mongolian spots,
presents as sharply demarcated macules or patches of highly varying sizes and shapes.
They may be small and isolated or very large and numerous. CDMs are blue-black
in color and very commonly located in the sacral region, buttocks, legs, or back
(Figure 1–4). CDMs have the highest incidence in African American, Hispanic,
Asian, and Native American infants. Histologically, the lesions are characterized by
melanin-containing melanocytes in the dermis. Over several years of life, the lesions
typically fade owing to darkening of the surrounding skin; however, some may per-
sist into adult life. They are benign and do not require treatment. Recognition and
documentation of CDM at birth is imperative, as they can be mistaken for bruises
if a question of nonaccidental trauma arises.

B
Figure 1–2. Pustular melanosis. A: A newborn with congenital, thin-walled pustules that rupture
easily. B: Hyperpigmented macules appeared by 10 hours of age. (Reproduced with permission,
from Kang S, Amagai M, Bruckner AL, et al., eds. Fitzpatrick’s Dermatology. 9th ed. 2019. Copyright ©
McGraw Hill LLC. All rights reserved. https://accessmedicine.mhmedical.com.)

Figure 1–3. Milia. Milia on the face of a 2-week-old infant with greatest number of milia on the
nose. (Reproduced with permission, from Usatine RP, Smith MA, Mayeaux, Jr. EJ, et al., eds. The Color
Atlas and Synopsis of Family Medicine. 3rd ed. 2019. Copyright © McGraw Hill LLC. All rights reserved.
https://accessmedicine.mhmedical.com.)
Miliaria
Miliaria is caused by obstruction of the skin sweat glands and may produce dif-
fering clinical presentations depending on the depth of obstruction. Superficial
epidermal obstruction will present with 1- to 2-mm grouped vesicles without ery-
thema distributed over the chest and neck. This is described as miliaria crystalline
(Figure 1–5). More commonly, sweat gland obstruction deeper in the epidermis
will cause papules or pustules with surrounding erythema in the same distribu-
tion and is called miliaria rubra. These lesions are influenced by environmen-
tal factors; namely lesions worsen clinically with higher temperatures and high
humidity, which predisposes the infant to an increase in sweat gland obstruc-
tion. Treatment includes removal from the predisposing environment to a cool
environment.

Figure 1–4. Congenital dermal melanocytosis. Congenital dermal melanocytosis (Mongolian spots)
on the back of a 1-year-old Black child. (Reproduced with permission, from Usatine RP, Smith MA,
Mayeaux, Jr. EJ, et al., eds. The Color Atlas and Synopsis of Family Medicine. 3rd ed. 2019. Copyright ©
Figure 1–5. Miliaria. An example of miliaria crystalline denoted by vesicular eruption over the trunk
of this patient. Miliaria rubra can simulate folliculitis. (Reproduced with permission, from Papadakis
MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2021. 2021. Copyright ©

CASE CORRELATION
See also Case 6 (Neonatal Herpes Simplex Virus Infection), Case 24
(Measles), and Case 26 (Stevens-Johnson Syndrome).
COMPREHENSION QUESTIONS
1.1 A term male infant is delivered by uncomplicated spontaneous vaginal delivery
(SVD) at 40 weeks’ gestation. On day of life 1, his mother raises concerns
about a “rash on his chest and face.” Upon examination, you note that he has
a splotchy, maculopapular, erythematous rash in the mentioned areas. What
would you expect to see on the differential of a complete blood count obtained
on this patient?
A. Neutropenia
B. Bandemia
C. Lymphocytosis
D. Eosinophilia
E. Increased white blood cells with toxic granules
1.2 While on rounds in the newborn nursery, you are asked by the mother of a
healthy 1-day-old Hispanic female infant about the congenital dermal melano-
cytosis (CDM) that you identified yesterday on the child’s left posterior thigh.
She anxiously states that she has a sister who had melanoma requiring excision
and chemotherapy. She asks you if the infant is at increased risk of skin cancer.
You reply that the infant has:
A. No increased risk of melanoma or other type of skin cancer
B. A two-fold higher risk of melanoma and/or other skin cancers
C. A four-fold higher risk of melanoma and/or other skin cancers
D. No increased risk of melanoma, but she is at 30% risk of her CDM becom-
ing a different type of skin cancer in the future
E. A 30% risk of her CDM becoming melanoma in the future, but no
increased risk of other types of skin cancer
1.3 Additionally, the mother in the previous question asks you if the infant’s CDM
will always look like how it does now. You reply that it typically fades over the
course of:
A. 1 to 2 days
B. 1 to 2 weeks
C. 1 to 2 months
D. 5 to 6 months
E. Several years

1.4 The mother of a 3-week-old infant brings him to the pediatrician’s office with
complaint of facial redness. The infant was born at term at a birthing center;
birth documents are not available. The mother states her pregnancy and deliv-
ery were uncomplicated, although her third trimester prenatal care was spotty
due to transportation issues. The infant had been doing well until 1 day prior,
when he developed redness with small bumps on the left side of his face. The
previous evening, he began crying inconsolably and began refusing bottles. He
finally took a bottle this morning, and his mother managed to get him to go to
sleep prior to bringing him to the appointment. On examination, he is sleeping
in his mother’s arms and cries loudly when transitioned to the examination
table. He has erythema with small vesicles over his left jaw angle that is warm
to the touch. What should be your next step in management?
A. Reassurance
B. Suggest lowering the temperature of the family’s house
C. Prescribe clindamycin and discharge home
D. Admit to the hospital for intravenous antibiotics
E. Obtain jaw plain films
ANSWERS
1.1 D. Eosinophilia. The description is that of a newborn with erythema toxicum.
Peripheral blood count may demonstrate eosinophilia in up to 20% of infants
with this condition. There is not increased white cells (answer E), lymphocytes
(answer C), bands (answer B), or neutrophils (answer A).
1.2 A. No increased risk of melanoma or other type of skin cancer. CDM is a benign
lesion without increased risk of malignant transformation (answer E). It is not
associated with other types of skin cancer (answers B-D).
1.3 E. Several years. Typically, CDM lesions fade over the course of years (not days
to months, as in answers A-D) because of darkening of the surrounding skin;
however, some may persist into adult life.
1.4 D. Admit to the hospital for intravenous antibiotics. This patient has symptoms
concerning late-onset sepsis, possibly with group B streptococcal infection or
herpes simplex virus. Unknown maternal and birth history should heighten
your suspicion for sepsis, along with findings such as fever or hypothermia,
irritability, poor feeding, lethargy, rash and skin color changes, lymphadenopa-
thy, and seizures. Reassurance (answer A), discharging home (answer C), or
treating for miliaria (answer B) would not be appropriate given his age and
clinical presentation. His cellulitis requires further evaluation with a complete
blood count, blood cultures, lumbar puncture, and intravenous antibiotics. An
x-ray (answer E) may be considered if there is concern for osteomyelitis of his
jaw; however, this should not be done before initiating treatment for sepsis.

CLINICAL PEARLS
»» A thorough history and physical examination are essential in diagnosing
infant rashes.
»» Many infant rashes are self-limited and do not require treatment. Offer
reassurance to worried parents.
»» Pustular melanosis lesions are filled with neutrophils, erythema toxicum
lesions are filled with eosinophils, and milia are filled with keratin.
»» It is important to recognize congenital dermal melanocytosis at birth and
document it accordingly, as the lesions can mistakenly be identified as
bruises in nonaccidental trauma cases.
REFERENCES
Hulsmann AR, Oranje AP. Educational paper: neonatal skin lesions. Eur J Pediatr. 2014;173:557-566.
Martin KL. Diseases of the neonate. In: Kliegman RM, Stanton BF, St. Geme III JW, Schor NF,
Behrman RE, eds. Nelson Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier; 2016:111-123.
Prok LD, Torres-Zegarra CX. Skin. In: Hay WW Jr, Levin MJ, Deterding RR, Abzug MJ, eds. Current
Diagnosis & Treatment: Pediatrics. 24th ed. New York, NY: McGraw Hill; 2018.

CASE 2
You are called to the nursery by the postpartum nurse to evaluate a 3-hour-
old female infant with tachypnea. She was born at 36 weeks’ gestation to a
38-year-old woman whose pregnancy was complicated by type 2 diabetes.
Initially, the diabetes was treated with metformin; however, due to inadequate
glycemic control, insulin was added during the second trimester. The mother
was nonadherent with blood glucose monitoring and insulin therapy, and her
hemoglobin A1C at delivery was 12%. Labor began spontaneously, and rupture of
membranes occurred 2 hours before delivery. The infant is on the warmer, weighs
4200 g, has a pulse of 140 beats per minute, and has respirations of 72 breaths per
minute with intercostal retractions and nasal flaring. She is jittery and plethoric. A
capillary glucose measured with the bedside glucometer is 30 mg/dL.
▶▶ What is the next step in the evaluation of this infant?

▶▶ What is the treatment for this infant?
▶▶ What are other possible causes of this infant’s tachypnea?

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countless number of pieces, and thus lay open the inside of it, and the
cave, if there were any there.
Some went away satisfied that all had been done that could be,
and there was no treasure there; others, that the original cave and its
contents remained undisturbed but all agreed that they had ventured
their share upon the sea of speculation, and should not try again right
away.
Soon after this, mesmeric clairvoyance became one of the reigning
topics of the day, and almost immediately the interest of Dungeon
Rock was again agitated. This time, one of the world-renowned singing
brothers, Jesse Hutchinson, was the chief actor, directed by a
mesmerized lady, who steadily affirmed the truth of the disconnected
history that had been handed down to them, and added her
declarations to those who had the firmest faith in the old saying of
wealth in Dungeon Cave.
The operations flagged not for days and weeks; and, when at last
Jesse gave it up, not as a delusion, but as a task too hard for him,
others kept on, and made the hole still deeper and broader. But they
too failed, and, for a long time, the hill was undisturbed save by
occasional picnic parties, or Sunday groups of young people, who
went there to enjoy themselves.
Now our scene changes from the quiet, unfrequented, hilly
woodland, to the limitless plains of the great West, where the waters of
America’s broadest and deepest lake ceaselessly lave its shores. It is
the hour of a boat landing, and any number of men, women, and
children, could be seen hurrying to the wharf, with the first whole dish
they could reach, be it wash-bowl, ewer, or skillet, teapot, pan, or pail;
and one general cry of “whiskey, whiskey,” was heard throughout the
ranks.
In a small building, that served for kitchen, parlor, and bedroom, to
quadruped and biped, two men, apparently near the same age, and
both past the years of youth, sat, or rather reclined, talking busily with
each other.
“Rum is a great curse, Marble.”
“Granted.”
“And, if a great deal ruins a man, a little, be it ever so little, injures
him.”
“Granted also, Long; but now look here. In our crew there are only
men; but I warrant that up yonder, when the boat landed, you might
have seen people of all kinds and colors flocking to the wharf. You well
know what they are after. Now answer me this one question. Would it
not be better for us to set the example by keeping whiskey for our own
gang, and thus prevent their going to the boat, than it is to apparently
countenance beastly drunkenness, by their drinking all they can obtain
at irregular intervals?”
Long hesitated, and Marble went on.
“I know your principles. I know you consider rum-drinking as the
one unpardonable sin; but, if you stop to think about it, you may bring
your orthodoxy to agree with my infidelity.”
“It may be so,” Long added, after a pause. “I have thought a great
deal on this subject, and am not yet decided. You have sold rum, have
you not?”
Marble nodded.
“Well, do you think what you have sold has done most—which?—
good, or bad?”
“Bad,” was the prompt reply.
“I thought as much,” answered Long; “but that is not what I was
going to speak of just now. I want to know how you would like the idea
of keeping a boarding-house.”
“First rate,” answered Marble. “We could drive four stakes into the
ground, stretch a bit of cloth over them, and name it the Marquet
Eating Saloon, where shall be kept all manner of provisions, viz.,
whiskey, to be had at the shortest notice.” And a droll smile rested in
the corners of Marbles mouth, and twinkled in his small eyes, as he
ceased speaking; while Long, as the picture came vividly before his
active imagination, threw back his head and laughed loud and long.
“That is not what I wanted, Hiram,” he said, soon stopping his mirth
and growing sober again. “There are a great plenty of such
establishments going up in all parts of the country. We need a real
framed house; and, if you would plan such a one as you think you
could keep properly, why, all is, we would find means to build it, and
have it done right away. You shall bring your wife on to manage, and
your children to inhabit it. You shall keep on being overseer. I will be a
wealthy land-holder. Jointly and severally we shall be honored for
inventing, or rather, for starting the great Marquet Iron Works, and, by
my faith, we shall live fat.”
Then the two men separated, each to his own place; and here it
may not be inapropos to describe them.
Long, who appeared to be chief director there, was tall, but rather
slightly built, with a long face, intelligent-looking, dark eyes, a high, but
not full brow, and thin lips, that partially disclosed a regular set of teeth.
Marble, who seemed like Long’s very right hand, was also tall, but
strong and robust, with sharp, bright blue eyes, light waving brown
hair, and a full white brow.
On the night after their conversation, which we have recorded,
Marble, who always, as Long said, if he put his hands to the plough,
not only did not look back, but did not look forward either, and only
attended to holding the plough, started from the settlement to reach a
small hill at a little distance, partly to select trees from the lot for their
house, and partly to think over the practicability of the scheme they
had been discussing. He was walking slowly along, with his eyes fixed
upon the ground, when, suddenly looking up, he found himself back to
the place whence he started.
“Can’t you go as far as you can see?” he muttered to himself,
starting again for the wood: but again he became lost in thought, and
again he found himself at the same place.
“Well if you can’t go as far as you can see you may go home,” he
said, casting a regretful look at the woodland, and turning away. It was
a habit he always had of talking to himself, and it saved him many
hours of trouble.
Soon after this, he started for his home away in old
Massachusetts, which, upon reaching, he found was not entirely
exempt from the joint hands of time and sorrow. He had been at home
from the West but a short time, when his youngest child, a boy of
thirteen, was taken sick; and thus his plans were frustrated. His
sickness was short and painful; and his burning cheeks and glassy
bright eyes told but too plainly to the father’s heart that George’s days
were numbered.
About this time he, too, became interested in clairvoyance. Before
going West, he had, at the request of a friend, consulted a
phrenological subject who predicted his departure, and also his
misfortune—for such she termed the death in the family. After finishing
her talk, she informed him that she sometimes told fortunes; and asked
if she might tell his.
He did not care about it; had little faith in such things, etc.; but, if
she would like to, he had no objections.
She run the cards over, and told him essentially what she had said
before; adding that, in the course of a specified time, she thought he
would be in steady business.
He was, at that time, all ready to go West with a party of men to
establish the Marquet Iron Works.
He went and returned. George died; but, as yet, no steady
employment presented itself.
While staying in Marquet, a young man, an entire stranger in
Massachusetts, had described Dungeon Rock to him as his place to
work, but told no names, even of the town or state where it lay. He
was, at that time, careless, or even skeptical about the matter; but,
after George’s death, he aroused himself, and concluded to
investigate, and, if he could, to understand the subject.
He came to Lynn, and, subsequently, to a distant relative in a
neighboring town. Here he staid some time; and upon one occasion,
feeling unwell, he determined to consult a clairvoyant in the place, who
was entirely unacquainted with him or his business. Accordingly, he
expressed a desire to have him consulted, and Mr. Wheeler, who was
going to a neighboring town, offered to stop and see him, and,
perhaps, invite him to his house, as Mr. Marble was there staying.
He went, and, as he entered the room and made known his errand,
the clairvoyant, whose name was Emerson, commenced talking, and
finally seated himself at the table and began to write with great rapidity,
speaking now and then to ask or answer questions, and taking very
little notice of his work.
He was young, apparently less than twenty years of age; but his
dark complexion and keen black eyes gave a look of maturity, which
his slight, almost petite figure, and long curling hair, instantly
contradicted. When he stopped writing, he folded and directed the
letter, and gave it to Mr. W. without a word of comment, having first
signed his own name to it as a medium.
“But the gentleman thought he might want to see you on some
other business,” Wheeler said, doubtfully, holding the document
between his thumb and finger.
“I presume it is there, sir,” was the reply; and the medium turned
away.
Mr. Wheeler left the house, and, instead of keeping on his way,
concluded to return with the letter. He did so; and, entering the room
where Mr. Marble was, gave him the letter, and told him to read it
aloud.
Marble did so; and, before he reached the end, Wheeler threw his
hat on the floor, and asked what he would take for half the rock, as he,
Wheeler, would like to go into company with him.
Marble did not answer until he had devoured the whole contents of
the letter, which really contained a great many mysterious and some
unaccountable statements concerning the business in which he then
was engaged. Among others, it stated that he would call there the next
day and go with them to the rock; which he did, accompanied by a
friend who generally mesmerised or put him to sleep. He threw himself
upon the ground beside the rock, when he reached it, and, after
becoming entranced, told how and where they must work, etc.
And, now that we have got them fairly started, we will go back a
single year, and try if we can tell a reasonable story. Soon after
George’s death, as we have said before, Mr. M. aroused himself, and
determined to investigate the subject of mesmerism. Opportunities
soon presented themselves. When staying at a public house, one
night, the porter came to him and said, “Madame Y. is here, and
wishes to see you.”
“Who is Madame Y.?” he asked, thoughtfully.
“I don’t know,” was the reply; “but she sent her name, and bade me
say she had told your fortune.”
An indistinct recollection seemed to cross his mind, but he only
said, “I will go,” and was accordingly conducted into her presence.
She recalled their former meeting, inquired as to the veracity of
what she had then said, and ended by telling him there was a very
good clairvoyant, Madame Maine, with her at that time, and, if he liked,
she would put her to sleep and have him examined.
He was at the time suffering from a recent attack of the Asiatic
cholera, which was accurately described by Madame M., even to the
time and place of his sickness, for which she wrote a prescription,
which he took in all faith.
She then went on to tell what he was to do for the future. “You will
dig for a pirate’s money,” she said, “and you will find”—here she
hesitated.
“A bugbear,” he said, laughing.
“The pirate, himself, sir,” she added, “or, rather what there is left of
what was once a pirate, and a treasure with him.”
“That is encouraging,” he said, concealing his unbelief “Can you
tell me where this money lies that I am to dig for?”
“It is somewhere by the sea-side, I think,” she answered; “less than
twenty miles from Boston.”
Well, he left with his confidence in mesmerism so much lessened
that he never used his prescription. A short time after that he met two
or three young men conversing upon that subject. They had heard
something of Mr. M.’s experience, and wanted to hear more.
“What is the most likely thing they ever told you?” one asked.
“That I should go digging for money,” he replied.
A burst of laughter followed this grave assertion, and they asked to
have it explained.
“Well the truth is this. Madame Maine told me that I was soon to be
engaged in searching, or rather digging, for a pirate and his money.”
“Do you know where it is?” asked one, whose name was Olds.
Marble laughed at the thoughtful look which had settled on their
faces, and answered, “No; she gave out when she had got about so
far, and could not tell the rest.”
“I’ll warrant it was down in Lynn!” exclaimed Olds.
“What do you know about Lynn?” Marble asked.
“I have been there, myself,” he answered, earnestly; “and I have
no doubt that there is money there. At any rate I advise you to try it.”
Soon after this Marble consulted a physician, who told him that he
needed a change; the salt air would be good for him; he had better pay
the sea-shore a visit. This decided him, for, as he afterward expressed
it, everybody and everything he met seemed to be pointing him away,
away.
“I will go and work a fortnight,” he said; and nobly well has his word
been kept.
Upon this he went and took a survey of the rock. It contained a
huge chasm, which he thought would lead to a cave, if there was one,
with a very little trouble. He commenced work in company with two
other men, and made slow work of it, too, as the rock was very hard,
and they had nothing to direct their motions, and nothing but hope to
live upon as far as the work in the rock was concerned.
It was about a year that they worked thus; then first one man, and
soon the other, became weary and discouraged, and left. The cave
was still as far distant as ever; faith had grown weak, and hope, which
formed so tempting a breakfast, seemed about to prepare a very poor
supper.
It is about this time that we find how great is the power of
perseverance. Mr. Marble, after the other men had left, continued the
work for some time with his only son, a young man about twenty years
of age. And thus, it was after working a year by the guidance of
mesmerism, that we find him consulting the first clairvoyant medium,
and this led him into the mystic labyrinths of spiritualism, or spiritual
philosophy.
The grounds which the medium took were substantially these: that
when, by the action of his friend’s mind, he was rendered unconscious,
some disembodied spirit took possession of him, and told what living
people did or did not know. He told Mr. Marble how to work in the hole
he had excavated, and, at one time, foretold a circumstance which was
of considerable importance. It was that within a certain number of
hours he would find a something to encourage him. It did not tell what,
and the number of hours included a week’s time. Four days after that,
an ancient-looking, rusty sword, with a leather-wound haft and a brass-
bound scabbard, was found in a large seam inside the rock. Soon after
being exposed to the air, the leather upon the handle crumbled away,
and the thick, blue mould on the brass began to wear off. The chasm
in the rock is still shown to visitors, and the prints where the sword lay
in the clayey soil were once to be seen, but have since been removed,
in the hopes of finding more relics.
This was a great event to build a hope upon, and it had its full
effect on the spirits of those interested. Dungeon Rock soon became a
place of particular interest to mediums. The well-known Mrs. Pike paid
it a visit; also Mrs. Freeman, who had, on a former occasion, directed
Mr. Marble to go to a certain street and number, in the city of Boston,
where he would find an aged, bed-ridden woman, who would be of use
to him.
He went, and discovered Madame Lamphier, to whom he made
known his errand as one who had come to have his fortune told.
“Fortin’! who says I tell fortins’?” was the spiteful ejaculation that
greeted him.
“Well, what do you tell?” he asked, convinced that she was the one
he sought.
“Why, I have a stone that I look in, and if any one has any
business, it generally comes up here,” she replied, doggedly.
“Well, I should like to have you look into it for me,” he said, in a
conciliatory manner.
Accordingly she drew out her stone, adjusted her glasses, and
commenced by seeing him in a deep dark hole, with something hung
up between himself and a pile of gold which he was trying to reach.
She then kept on, and described a young girl, as she saw her, about
twelve years of age, who was to be of future service to him or his work.
“And you will not get through with the partner you have now, either!”
she said, decidedly.
“Well I was told that same thing about my last partner,” he
muttered, half to himself and half aloud.
“What was his name?” she asked.
“What do you think?” he answered, Yankee fashion.
“I see a large W.,” she said musingly.
“Well that is right; his name was Wheeler,” he replied. “What do
you think of him?”
“I don’t know nothing about him,” said the old woman, cautiously;
“but I see one very mean thing that he did.”
“You mean to say he is a dishonest man, then?” Mr. Marble said,
for the sake of getting along faster.
“No I don’t,” she said fearfully; “he is not dishonest, but he took the
advantage.”
“Well, never mind that, tell me about my present partner; do you
know his name?” Marble said again, to turn the theme.
“I see the same large W.,” she said, “but it looks finer and
handsomer.”
“Really, quite a compliment; anything more?”
“Yes; I see a great deal of wood.”
“Well, that it is the land that I work on,—is it not?”
“No; it is something in connection with your partner. I see him now.
He is young—light-complected for a black-eyed person. There is
something strange about his eyes; they glare at me like coals of fire.
He is not very handsome, but there is a taking way with him that
makes the gentlefolks like him at first sight. Splendid young fellow, ah!”
“Yes,” said Marble, “fine man; is he not?”
An Indian-like grunt escaped her, and she said, “You have not told
me what that wood means.”
“Wood—why, it is his name—is it not?”
“Yes,—I think so. It is gone now,” she said, and prepared to lay
aside her stone.
“You spoke about his being young; is he not old enough for that
work?” Marble asked.
“In years he is,” she answered, moodily.
“Not old enough in business, then, you meant,” he continued.
“In iniquity, did you say?” she asked.
Mr. M. saw he could get nothing more from her that day, and soon
took his leave.
Time passed. Mr. Marble’s confidence was betrayed, and his plans
frustrated. Mr. Wood took the whole responsibility upon himself, and
tried to buy the rock. Finding he was foiled in this, he hired a man to go
to work against Mr. Marble. In this he failed also, and, instead of
getting the other half of the business, he lost the half he already had.
After this, Mr. Marble had no more partners. The man Mr. Wood had
hired kept on working there in his own employ. Marble had built a small
house for his own accommodation some time before, and one or
another of his or Mr. Wheeler’s family had done the work there, and
kept them comfortable. Now the hired man offered to bring his wife
there to reside, which he did a short time before Mr. Wood left. Mr.
Marble’s family had been staying in the vicinity a while, but long before
the cold weather they returned to their home in the interior, and nothing
now remained to cheer the unbroken monotony of his way. The long,
and chilling winter of the year eighteen hundred and fifty-five will be
remembered a great while by the man whose work was to find a way
to Dungeon Rock.
With the summer came plenty and warmth again; the little garden
was planted, the carriage road laid out and built, where before there
was scarcely a path; a friend gave him two hundred dollars, to be
refunded when he found himself able. With this he laid the foundation
for a large stone building, to be erected in the octagon form, somewhat
after the fashion of the gray and sombre Oriad. Then another person
seemingly still more of a friend, was directed (also by the spirits) to
forward two or three thousand dollars to have the work go on. This was
a brilliant proposal; but owing to some mismanagement or mistake it
was never carried into effect. A short time before this a spring was
discovered upon the low land near the rock, which proved to be a great
curiosity. Then a small wooden house was erected, in addition to the
one already there, into which the remainder of Mr. Marble’s family,
consisting of a wife and daughter, removed.
Soon after this, a party of people from Charlestown and Boston,
who had lately become interested in the place, were there on a visit,
when a medium being entranced, purported to speak from the spirit of
Sir Walter Scott, and requested a lady who was present to make Mr.
Marble a present, such as he (the spirit) would dictate. It afterwards
came in the shape of a flag-staff, eighty feet in length, which was firmly
planted in the place formerly excavated by the Hutchinsons. Then a
flag with the appropriate inscription, “Thy faith is founded on a rock,”
was raised upon it by the lady’s own hands. There was no fear of
starvation that winter, but the snow was wondrously deep, and the
hollows were piled softly up, almost even with the hill-tops.
When the spring opened, company came thronging again to the
rock, to see and hear all that was wonderful and strange; for the
popularity of the place had been steadily increasing, and the world is
ever on the lookout for something new. All that spring and summer
company and visitors, picnic parties and relatives, were coming in
rapid succession, and no material change was made, either in the
work or their way of life.
Fresh, dreamy September, like a maiden just passing from
childhood to her teens, came softly on. There is but one more incident
of interest to note; that is, when the great philanthropist, and
remarkable medium, John M. Spear, paid it a passing visit, in company
with two or three other mediums.
And now our history is finished.
There is a small room, away in the very top of a block of buildings,
where the sun beats scorchingly down, and the dust whirls in clouds
through the narrow street. And there, where affluence is unknown, and
elegance unconsulted,—where no rich tapestry shields the artist’s
easel from the light,—is a work of magic art and mystic mystery, which
has been seen by hundreds, and will be by thousands. It is a rare
bright picture—a childish, dimpled face, with deep, wondrous blue
eyes, and thick clustering curls; one round arm is flung over the
shaggy neck of a large black dog, as if to show how perfectly the
spiritual part of nature can overcome the animal; and the whole picture
represents some half-embodied ideal, which is in future years to
become a reality. There are, undoubtedly, the touches of the old artists,
Ben West, Raphael, and Angelo, about the work, and their power may
not be yet extinct; but the world is not ready for such ideas as yet; it
must receive the truth gradually.
But, the picture of “Natty, a spirit,” has nothing to do with our
present work. It is its executor of whom we would speak. He is an artist
of some celebrity, and his painting of the spirit child has made him
famous. He professes to have distinct visions of spirits in human form;
snatches of landscapes, birds, flowers, and, indeed, almost every thing
that can be seen in the natural world. He is a reflective, and rather a
peculiar man; there are silvery threads in his hair, and furrows on his
brow, as though he thought a great deal. And he it is that has been
chosen to do the work of planning and directing the laying out of
Dungeon Pasture, which is to be called “Iowah;” a name which the red
man gave it long ago, and which signifies “I have found it.”
The legend of that name is as follows: “Several hundred years ago
the united forces of pestilence, famine, and war, had so reduced a
large tribe of Indians, that only a very few remained, and, after calling a
council of their wisest men, these few determined to leave the home of
their fathers and found a new settlement; accordingly, they started
through the trackless wild on their vague expedition; they passed
“Through tangled Juniper, beds of reeds,

Through many a fen where the serpent feeds,
And man never trod before;”
and at last came to the foot of a large hill, with an enormous ledge
upon the top. Upon climbing this, they saw spread out before them a
panoramic view of what they knew would prove a good hunting-
ground, for it had forests for game and water for fish. Then a loud cry
of “Iowah! Iowah!” made the welkin ring, and the whole party
encamped that night in the large, open cave, before commencing their
work. They called the river Saugus, which means broad or extended,
and when the tribe grew large and strong, and reached away down to
the great “Father of Waters,” they called the two beaches Nahaunte,
which means, the brothers, or the twins.
All this is to be revived again; the woodland to be laid out in
groves, and parks and forests; the spring in the cave to be cleared
again, and its brink bordered by marble slabs; the ancient, scattered
treasures will be gathered up, bright flashing diamonds, clear white
seed pearls, with heavy gold settings, and antique jewelry and
ornaments, that have been a long time lying useless. The heavy iron-
bound box, that was left there, has been disturbed and broken by the
action of the earth, and its contents are now duly mixed up with equal
quantities of dirt, loose stones, and rubbish, which the water from the
spring, all choked up as it is, has for the space of two hundred
consecutive years been laying. There was once a case of silks left
there, but, as the cave is not perfectly air and water tight, the
probability is that, although they look the same as ever, there is not
much durability to them. The grave of Arabel, Veale levelled down, but
the spot is still pointed out by mediums, and, although the tree under
which Harris laid her has long since decayed, another has grown up
very near where that was supposed to stand, which is now in the
centre of a thriving garden.
Cathrin’s sepulchre is the “rock of ages,” and traces of her remains
will be found upon one of the shelving places in the cave. The child
was buried, but
“The string of pearls and the lock of hair,

And the ring of gold that it used to wear,”
will be found by Cathrin’s side, where Veale, with his superstitious
reverence, placed them.
The cave will be found in two separate apartments, beside the
entrance, which clairvoyant mediums see as another room. Veale
himself, or rather his bones, will be found in the outer, or largest room,
together with the remains of his shoemaking tools. The other contents
of the rock we leave for time to discover, and the sagacity of the
“Excavator” to make known.
The medium that Madame Lamphier saw four years ago, at the
age of twelve, has been employed more or less, for five or six weeks
past, in writing this little work, which we now send on its way, without a
fear that its mission will ever be unaccomplished. The time for all
things to be done is ordered; and when we have said all that can be
known about such a place as Dungeon Rock, there still remains one
question unanswered—one doubt unremoved. Time alone can verify
what hundreds have told, either by impression, clairvoyance, or
entrancement, that there still remains a cave there, and that the
present laborer, Mr. Hiram Marble, otherwise known as the Excavator,
shall be the one to discover it.
LINES COMMUNICATED TO A
CIRCLE AT DUNGEON ROCK,
FEBRUARY 22d, 1856.
Far away from the voice of the rolling sea

A noble banner is waving free,
With its motto of blue on a pure white ground,
And a single stripe of scarlet around.
America’s tri-color, red, white, and blue,
Flutters softly there all the long day through.
On the high, firm rock, ’bove the grassy strand,
With its heavy brace, does the flag-staff stand;
While not far down on the rough hill’s side
Is the small, rude cot, where the workers abide.
We know, ere the cold winter flitted o’er,
That want peered in through the open door;
But hearts were willing to boldly strive,
And hope and faith kept the soul alive;
So, spite of famine’s half-looked-for shock,
The work still prospered in Dungeon Rock.
Strong hands kept picking the stone chips out,
And forcing the long, circuitous route;
Strong hearts were waiting, for well they knew
That the summer would bring them enough to do.
With curious eyes, and a curious name,
Or open purses and open fame.
But the stranger’s scorn and the stranger’s love
Were never valued true friends above.
Years pass like the hours of a summer day,
And leave no memento to mark their stay.
We have told of the faith in the Rock alive
In the year eighteen hundred and fifty-five.
Let us turn time’s current, and backward go,
And see what new wonders her book will show,
By skipping two centuries, just to derive
The knowledge of sixteen fifty-five.
There’s still a dark wood, and a winding stream,
Where the cold, bright stars, and the moon’s pale beam,
Light up a low path, by the underbrush hid,
And gild the smooth plate on the coffer’s dull lid.
There are hurrying footsteps and stifled tones
In that lonely ravine of earth and stones;
’Tis the hiding-place of a pirate band,
Who came from a distant, brilliant land,
And their burden of spoils from the broad, high seas
They have borne to that forest of woodland trees,
Where the wild wolf howls in his dismal den
Or makes his home in that pirate’s glen.
They are startled now, those men so brave,
And are taking their treasure to Dungeon Cave.
Away through the woods that once skirted the vale
They had made for themselves an invisible trail;
And, now that the night was so dark and still,
They were moving their spoils from the glen to the hill.
An iron bound box, with its shining gold,
And a limestone fossil, pure and cold,
On its soft, white cotton, was resting there,
Treasured with superstitious care.
There are noble hearts in that lonely home,
And Harris, the leader, is soon to come.
They hear him now, as they firmly tread
O’er the fallen leaves and the flowers dead:
“Halt”—the low, deep summons is soon obeyed,
And Harris moves out from the tall tree’s shade.
There’s a light in his eye, and a stern command
In the haughty wave of his ungloved hand,
As he lifts the cap from his high, white brow,
And says, “My men, be ready now.
Have you ta’en the strong box from the vessel’s hold,
And well secured it, with all its gold?
Have you counted the diamonds we stole from the berth
Of the fair Cristelle, on that night of mirth?
Have you closed my coffers? In short, my men,
Have you cleared all the trash from our silent glen?
For I have an inkling, from what I have heard,
By the foundery, to-night, that the settlers have stirred,
And will soon be for finding the men of ease,
That dare to murder on God’s high seas.”
“We have moved them all,” was the men’s reply,
As Harris gazed at the moonlit sky;
“We have moved them all; but what, your honor,
Shall we do, to-night, with our fair Madonna?
Shall we leave her alone in the glen to abide?
Will she make for Sir Wolf a fitting bride?
Or, will she tell tales when they come to look?
For I’ll risk a woman to find our nook.”
“Peace!” thundered Harris, “and no more fun;
Ye are seven in number, in purpose one.”
He added, more kindly, “But now, move on,
For to-night our labor must all be done.”
Then he quickly turned toward the lonely glen,
And left in the darkness that band of men.
We can tell no more. But the lady fair,
Ere the next day’s sunshine reached her there,
Had followed the winding, woody road,
And found on the hill-side a new abode.
At noon she saw from the high cave door,
A party of men and torches four
Creep slowly in through the tangled green,
Where the pirate robbers had last been seen.
Three times did the lady fair look down;
Three sunsets she saw on that little town;
Then she rested her fair, pale face alone,
By the cool, bright spring in the hollowed stone;
And that night, when the pirates came home from the dell,
They buried the form of proud Arabel.
Then years passed on and another bride
Blessed the cavern home on the high hill-side;
But the pirates were traced to their home by the sea,
And, of all the seven, there escaped but three.
One of these fled to his rocky home,
And dared not away from the cave to roam.
But the merry Cathrin, the pirates bride,
Mourned out her young life, that year, and died.
And the sturdy Veale, who could ever bear
The darkest storm of both sea and air,
Became a coward, and dared not brave
The suspicious look of a lowly grave.
So he carefully laid that form of clay
On a shelving rock in the cave away;
And he flung the pure folds of her own white dress
O’er her marble brow, in that dark recess.
Then he wandered on, and lived and grew,
Like the rest of Lynn people, tied to a shoe;
For he dared not betray the gold, so bright,
Lest he should be murdered, some silent night,
But, at last, the great earth felt the earthquake’s shock,
And Veale was immured in the prison rock.
Then time fled on, and the silent life
Of nature alone by the rock was rife;
Till the baby city had a regular blow,
Which shattered the stones to their base so low,
And rattled them down till they closed the mouth
Which the earthquake had left toward the sunny south
The good effects which this blowing made
Were to use the powder, and help the trade.
Then again was the solitude deep and still,
By the pirate glen, on Dungeon Hill.
But curious minds spied the legends out,
And a new scene of labor was brought about.
A mesmeric lady, of wondrous fame,
And a band of brothers, with as wide a name,
Became interested, and tried for a while
The rocks of the Dungeons high roof to unpile.
But, though they grew faint, we believing ones say
That Jesse the talented, Jesse the gay,
The brother that shone, ere he passed from sight,
Like a trammeled star of unbounded might,
This scene of his labor has not forgot,
But is lingering still round the lonely spot,
Where the brothers shall some time again unite,
And sing for the dungeon with all their might
The good they did is, that the heavy bole
Of the flag-staff rests low in the Hutchinson hole.
Then, again, the excitement of Dungeon Rock
Forgot to be the general every-day talk;
And the forest was valued, like other land,
For the visible worth on its rocky strand.
For long, long years was the silence unbroke,
Save the owlet’s dull hoot, or the woodpecker’s stroke
But, lo! the hill-side must once and again
Be made to resound to the works of men
And a long, dark cavern tells half the fears
And all the hopes of long, weary years.

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Case Files Pediatrics, 6e (Oct 6,

• USMLE- style questions, clinical pearls, and review

• Learning system proven to help you excel in the

TOY • HORMANN YETMAN • McNEESE

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eBook conversion by codeMantra

To pediatricians everywhere, who are well known as “the nicest doctors”,

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Heba A. Ahmad, MS4

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Mastering the cognitive knowledge within a field such as pediatrics is a formidable

HOW TO GET THE MOST OUT OF THIS BOOK

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Table 1 • SYNOPSIS OF ENTRUSTABLE PROFESSIONAL ACTIVITIES

3. The Analysis of the case is composed of two parts:

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LISTING BY CASE NUMBER

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36 Nursemaid’s Elbow (Radial Head Subluxation) 335

LISTING BY DISORDER (ALPHABETICAL)

5 Accidental Drug Ingestion 55

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32 Atopic Dermatitis and Contact Dermatitis 299

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26 Stevens-Johnson Syndrome 247

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Part 1 Approach to the Patient

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Part 1. Approach to the Patient

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rate and streakiness on a chest radiograph is more likely to have transient

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2. Ultrasonography is a fairly inexpensive modality that requires little or no seda-

Part 2. Approach to Clinical Problem Solving

MAKING THE DIAGNOSIS

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ASSESSING THE SEVERITY OF THE DISEASE

RENDERING TREATMENT BASED ON THE STAGE OF

FOLLOWING THE RESPONSE TO TREATMENT

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Part 3. Approach to Reading

WHAT IS THE MOST LIKELY DIAGNOSIS?

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“The mother did not receive prophylactic steroids prior to birth.”

WHAT SHOULD BE YOUR NEXT STEP?

In particular, the student is accustomed to regurgitating the same information

WHAT IS THE MOST LIKELY MECHANISM FOR THIS PROCESS?

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WHAT ARE THE RISK FACTORS FOR THIS CONDITION?

WHAT ARE THE COMPLICATIONS ASSOCIATED WITH

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complication of Kawasaki syndrome is coronary artery aneurysm and thrombosis.