Current Clinical Strategies

Pediatric History and Physical Examination
Fourth Edition

Elizabeth K. Albright, MD

Current Clinical Strategies Publishing
www.ccspublishing.com/ccs

Digital Book and Updates
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Copyright © 2002-2003 Current Clinical Strategies Publishing. All rights reserved. This book, or any parts thereof, may not be reproduced or stored in an information retrieval network without the permission of the publisher. No warranty exists, expressed or implied, for errors or omissions in this text. Current Clinical Strategies is a registered trademark of Current Clinical Strategies Publishing Inc. Current Clinical Strategies Publishing
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Contents
Medical Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pediatric History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pediatric Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Physical Examination of the Newborn . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Discharge Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Discharge Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Prescription Writing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Procedure Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Developmental Milestones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cardiovascular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dyspnea and Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pulmonary Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wheezing and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stridor and Oropharyngeal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . Hoarseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cough and Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peritonsillar, Retropharyngeal or Parapharyngeal Abscess . . . . . . . . . . Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Croup (Viral Laryngotracheobronchitis) . . . . . . . . . . . . . . . . . . . . . . . . . Bronchiolitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urinary Tract Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lymphadenopathy and Lymphadenitis . . . . . . . . . . . . . . . . . . . . . . . . . . Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute Abdominal Pain and the Acute Abdomen . . . . . . . . . . . . . . . . . . Recurrent Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Persistent Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jaundice and Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hepatosplenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
13
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. . . . . . . . . . . . . . . . . . Toxicological Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amenorrhea . . . . . . . . . . . Kawasaki Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Developmental Delay . . . . . . . . Coma and Confusion . . . . . . . . . . . . . . . . . Bruising and Bleeding . . . . . . . . . . . . . Hematologic and Rheumatologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Swelling and Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Behavioral Disorders and Trauma . . . . . . . . . . . . . . . . . Abnormal Vaginal Bleeding . . . 99 . 95 Index . . . . . . . . . . . . . . . . . . Pelvic Pain and Ectopic Pregnancy . . . . . Apnea . . . . . . . . . . . . . . . Neurologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rash . . . . . . . . . . . . Dermatologic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enuresis and Urinary Frequency . Proteinuria . . . . Delirium. . . . . . . . . . . . . Psychiatric History . Failure to Thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Melena and Lower Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . .Hematemesis and Upper Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Gynecologic Disorders . . . . . . . . . Diabetic Ketoacidosis . Spells and Unusual Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Polyuria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Renal and Endocrinologic Disorders . . . . . . Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 63 64 65 67 67 68 69 71 73 73 74 75 77 78 81 81 82 83 85 85 87 90 91 92 94 Commonly Used Abbreviations . . . . . Attempted Suicide and Drug Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seizures. . . . . . . . . . . . . . . . . . . . . . . . . .

fever. informant (parent). complications (eg. hematuria. nail/hair changes. Lungs: Cough. Safety: Child car seats. bicycle helmets. Medications: Names and dosages. joint pain. constipation. including when and how it began. lumps/bumps. pharyngitis. Endocrine: Growth delay. type of delivery. amount of flow. length of hospital stay. obstetrical complications. smoke detectors. Parental level of education. Neurological: Headache. bruising. Cardiovascular: Chest pain. hospitalizations. Musculoskeletal: Weakness. asthma. smoking. Developmental History: Age at attainment of important milestones (walking. recurrent abdomi­ nal pain. behavioral changes. otitis media. scoliosis. Genitourinary: Dysuria. smoking. syncope. jaundice). renal or GI disease. allergies. Immunizations: Up-to-date? Allergies: Penicillin. Ear. murmurs. spitting up. cancer. seizures. moles. Relationships with siblings. amount taken each feed. Skin: Rashes. adults. sexual activity. Social History: Family situation. Gastrointestinal: Nausea/vomiting. codeine? Family History: Medical problems in family. drugs. infection. past diagnostic testing. change in feeding habits. Review of Systems (ROS) General: Overall health. History of Present Illness (HPI): Describe the course of the patient's illness. STDs. Apgar scores. excessive thirst/fluid intake. talking. shortness of breath. aggravating or alleviating factors. vaginal discharge. School grade and performance. operations. peers. age. Eyes: Visual problems. sex. behavioral problems. . Chief Compliant (CC): Reason that the child is seeking medical care and duration of the symptom. Perinatal History: Gestational age at birth. fatigue. wheezing. asthma. polyuria. cardiac. pertinent positives and negatives. throat: Frequency of colds.History and Physical Examination 5 Medical Documentation Pediatric History Identifying Data: Patient's name. seizures. significant medical conditions. alcohol. nose. Past Medical History (PMH): Medical problems. diabetes. diabetes. birth weight. blood in stools. diarrhea. self-care). character of the symptoms. tuberculosis. menses duration. weight loss. gait abnormalities. Nutrition: Type of diet. polyphagia. eye pain. including the patient's disorder.

cryptorchidism. bruits. bleeding. hearing. discharge. tenderness. prolongation of expiration. Measurements: Height. hydrocele. mobility and consistency of cervical. hoarseness. Breasts: Turner stage. cataracts. shape. respiratory movements. S4). meningitis). moaning (serious illness. capillary refill (in seconds). pallor. cleft lip). fremitus. conjunctiva. effect of change of position. Heart: Location of apical impulse.6 History and Physical Examination Pediatric Physical Examination Observation: Child's facial expression (pain). Rectum and Anus: Erythema. chronically ill. size. dilated veins. Weak cry (serious illness). inguinal masses. mobility. phimosis. masses. masses. size. discharge. crackles. discharge. blood pressure. Female Genitalia: Imperforate hymen. Anal tone. hernia. imperforate anus. symmetry. axillary. Brushfield's spots. café au lait spots. transmission). umbilicus. Skin: Cyanosis. bossing. red reflex. S2). high­ pitched cry (increased intracranial pressure. patency. Genitalia: Male Genitalia: Circumcision. Nose: Shape. Eyes: Pupils equal round and reactive to light and accommodation (PERRLA). nipple discharge. acutely ill/toxic. dull. Lungs: Breathing rate. excoriation. extraocular movements intact (EOMI). exudate). response to social overtures. Throat: Tonsils (erythema. temperature. postnasal drip. downturning. fissures. . grunting (respiratory distress). bruits. Regular rate and rhythm (RRR). Does the child appear to be: (1) Well. tension). fontanelles (size. depth. plot on growth charts and determine growth percentiles. position of trachea. wasted. expansion. jaundice. splenomegaly. Thorax: Shape. shiny. position in cycle. pulse. Mongolian spots. mucosa. cleft palate. pubertal changes. tenderness. hernia. murmurs (location. asymmetry. corneal opacities. fundi. breath sounds. pericarditis). intensity grade 1-6. Neck: Torticollis. bulging). first and second heart sounds (S1. thyroid nodules. visual acuity. shape. Head: Size. mucus membrane color and moisture (enanthem. Abdomen: Contour. hair distribution. metabolic disorder). prolapse. Comparison of brachial and femoral pulses. epicanthic folds. rashes. facial asymmetry. Rebound tenderness. bowel sounds. clitoral hypertrophy. Ears: Pinnas (position. visible peristalsis. labial adhesions. weight. Epstein's pearls). or malnourished? (2) Alert and active or lethargic/fatigued? (3) Well hydrated or dehydrated? (4) Unusual body odors? Vital Signs: Respiratory rate. dullness to percussion. head circumference in children �2 years. tongue. hypospadias. wheezing. Mouth: Lips (thinness. Body position (leaning forward in sitting position. fissures. and inguinal nodes. strabismus (eye deviation). Interaction with caretakers and examiner. symmetry. masses. gallops (S3. edema. molding. gynecomastia. skin turgor. dilated veins. anal reflex. stridor. cephalohematoma. tympanic membranes (landmarks. hemangiomas. epiglottitis. hepatomegaly. tympany. rhonchi. supraclavicular. teeth. Lymph Nodes: Location. size of testes. erythema. nevi. pitch. size). intercostal or substemal retractions. lymphadenopathy.

X-rays. . simian lines. and Achilles reflexes (graded 1-4). cyanotic. and give reasons that support the working diagnosis. Respiratory: Acrocyanosis. chloride. rigidity. Distant heart sounds (pneumothorax). nasal flaring. tender­ ness. and discuss each problem separately. rooting. and consultations. swelling. pilonidal dimple. Neurological Examination: Behavior: Level of consciousness. pilonidal cyst. Laboratory Evaluation: Electrolytes (sodium. Spine and Back: Scoliosis. phimosis. hernia. mucoid vaginal discharge or blood streaked discharge (normal). urinalysis (UA). murmurs. Head: Lacerations. pitting of nails.5 cm below the right costal margin). muscle tone. plantar reflexes Neonatal Reflexes: Babinski. Developmental Assessment: Delayed abilities for age on developmental screening test. hernias. Edema (grade 1-4+). masses. Give reasons for excluding other diagnoses. flat feet. umbilicus. clubbing. A "click" felt on rotation of hips indicates developmental hip dislocation (Barlow maneuver). grunting. spleen span. Physical Examination of the Newborn General Appearance: Overall visual and auditory appraisal of the completely undressed infant. grunting (respiratory distress). emotional status. metabolic disorders). red reflex. platelets. laboratory studies. head circumference. Motor system: Gait. differential). Reflexes Deep Tendon Reflexes: Biceps. medications. Neck: Flexibility and asymmetry.Physical Examination of the Newborn 7 Extremities: Bow legs (infancy). redness. Plan: Describe therapeutic plan for each numbered problem. tension). Superficial Reflexes: Abdominal. pupil size. suck. hematocrit. cyanosis. nephromegaly. grasp. bicarbonate. Male Genitalia: Hypospadias. temperature. intelligence. pale. Discuss the differential diagnosis. potassium. cephalohematoma. Jaundice (abnormal in the first day of life). Vital Signs: Respiratory rate (normal 40-60 breaths/min). Unusual body odors. Fontanelles (size. fullness. retractions. triceps. BUN. rhythm. WBC count. sacral hair tufts. Extra digits. milia (yellow papules). Eyes: Scleral hemorrhages. Anal patency Skin: Pink. cremasteric. Landau. skull molding. antibiotics. Comparison of brachial and femoral pulses. Mongolian spots (bluish patches). strength (graded 0 to 5). high-pitched cry (increased intracranial pressure. Palpation of clavicles for fractures. Heart: Position of point of maximal impulse. creatinine). tonic neck reflexes. caput. Assessment: Assign a number to each problem. brachioradialis. cataracts. Weak cry (serious illness). presence of both testes. patellar. knock knees (age 2 to 3 years). tenderness over spine or costovertebral tenderness. CBC (hemoglobin. heart rate (120-160 beats/minute). Anal patency Female Genitalia: Interlabial masses. Moro. Liver span (may extend 2. Mouth: Palpate for cleft lip and cleft palate. including testing. Joint range of motion. Abdomen: Asymmetry.

Progress Notes Daily progress notes should summarize developments in the patient's hospital course. consolability. Objective: General appearance. problems that remain active. symmetry of facial movements. plans to treat those problems. Feedings. daily weights. Assessment and Plan: This section should be organized by problem. sacral hair tuft. Physical exam. alertness. pulse. Laboratory Evaluation: New test results. with particular attention to active problems. a "click" felt on rotation of hips (Barlow maneuver. maximum temperature over past 24 hours. plantar reflex. grasp reflex. Discharge Note Date/time: Diagnoses: Treatment: Briefly describe therapy provided during hospitalization. respiratory rate. Circle abnormal values. Studies Performed: Electrocardiograms. Example Progress Note Date/time: Subjective: Any problems and symptoms should be charted. A separate assessment and plan should be written for each problem. Discharge Note The discharge note should be written prior to discharge. Discharge medications: Follow-up Arrangements: . and arrangements for discharge. CT scan. Current medications: List medications and dosages. Vitals. Emphasize changes from previous physical exams. pilonidal dimple or cyst. activity. Neurologic Examination: Tone. Moro reflex. hip dislocation. Progress notes should address every problem on the problem list. Appetite. root reflex. including antibiotics. and cardiovascular drugs. pain or fussiness may be included. simian lines. temperature.8 Progress Notes Extremities: Extra digits. fluid I/O (inputs and out­ puts). suck reflex. blood pressure. including chest and abdomen. surgery. develop­ mental hip dislocation). symmetry of extremity movement.

including pertinent physical exam and laboratory data. Diagnostic Tests. Invasive Procedures: History. diet. treatment. Physical Examination and Laboratory Data: Describe the course of the patient's disease up until the time that the patient came to the hospital. and describe the present status of the patient. Copies: Send copies to attending. including evaluation. Prescription Writing • • • • • • • Patient’s name: Date: Drug name and preparation (eg. consultants. and indicate who will take care of the patient. medications. Discharge Medications: List medications and instructions for patient on taking the medications. Hospital Course: Describe the course of the patient's illness while in the hospital. Discharged Condition: Describe improvement or deterioration in the patient's condition. Discharge Instructions and Follow-up Care: Date of return for follow-up care at clinic. Disposition: Note the situation to which the patient will be discharged (home). clinic. and outcome of treatment.Discharge Summary 9 Discharge Summary Patient's Name and Medical Record Number: Date of Admission: Date of Discharge: Admitting Diagnosis: Discharge Diagnosis: Attending or Ward Team Responsible for Patient: Surgical Procedures. tablets size): Lasix 40 mg Quantity to dispense: #40 Frequency of administration: Sig: 1 po qAM Refills: None Signature . Problem List: List all active and past problems.

talking a few words. babbles. Note that the parents and patient were given the opportunity to ask questions and that the parents consented to the procedure in writing. passes cube hand to hand. bears some weight on legs. orients to voice. anesthesia method. marks with crayon. explores environment. including sterile prep. feeds self crackers. enjoys looking around. Specimens: Describe any specimens obtained and lab tests that were ordered. sits well when propped. and outcome. cruises. laughs. recognizes parent. Walking. such as the CBC and electrolytes. Lab tests: Relevant labs. pincer grasp. devices used. Developmental Milestones Age 1 month Milestones Raises head slightly when prone. Procedure notes are brief operative notes. holds head up. Procedure Note Date and time: Procedure: Indications: Patient Consent: Document that the indications. alerts to sound. Anesthesia: Local with 2% lidocaine. regards face. risks and alternatives to the procedure were explained to the parents and patient. Sits unsupported. pulls to stand. Complications and Estimated Blood Loss (EBL): Disposition: Describe how the patient tolerated the procedure.10 Procedure Note Procedure Note A procedure note should be written in the chart after a procedure is performed. reaches for familiar objects. patient position. feeds self with bottle. imitates actions. uses raking grasp. ana­ tomic location of procedure. throws objects. drinks from a cup. sits without support. says mama/dada discriminantly. Description of Procedure: Briefly describe the procedure. understands no. coos. grasps rattle. Crawls. plays pat-a­ cake. Smiles. Rolls front to back and back to front. moves extremities equally. 2-3 months 4-5 months 6 months 8-9 months 12 months .

copies parents. catches ball. draws a circle. knows pronouns. skips. draws three part man. Jumps over objects. Parallel play. points to body parts. Removes shoes.Developmental Milestones 11 Age 15-18 months 24-30 months Milestones Comes when called. prints first name. scribbles. knows first and last name. knows more than 250 words. memorizes songs. 3 years 4 years 5 years . walks backward. follows 2 step command. Group play. Hops. uses plurals. plays cooperatively. jumps with both feet. runs. takes turns. builds tower of 2 blocks. walks up and down steps. shares. follows game rules. Dresses and undresses. uses 4-20 words. holds pencil. knows colors. hops on one foot. spoon feeds self. knows address and mother's name.

12 Developmental Milestones .

Progression of pain. Extremities: Unequal or diminished pulses (aortic coarctation). Positions that accentuate or relieve the pain. location. myocardial infarction. pallor. rhonchi. exertion. dyspnea. Crackles. dermatomal lesions. trauma. stresses. heartburn. during sleep. distress. head­ aches? Light-headedness. Swelling. third heart sound (S3). wheeze. asthma. Vital Signs: Pulse (tachycardia). BP. respirations (tachypnea).Chest Pain 13 Cardiovascular Disorders Chest Pain Chief Complaint: Chest pain. cramps. tetany. Social History: Significant life events. Does the pain interfere with the patient's daily activities? Have favorite sports or other activities continued? Cardiac Testing: Results of prior evaluations. S4 gallop (more audible in the left lateral position). echocardiograms. xiphoid process tenderness. aggravating and relieving factors (inspiration. Note whether the patient looks “ill” or well. Skin: Cold extremities. tenderness. trauma. Historical Findings for Chest Pain Acute pain? First time? Systemic symptoms? Duration of complaints? Exertional? Syncope? Palpitations? Cough? Localized? Reproducible? How? Associated symptoms? Abdominal pain. vomiting. murmur. hepatomegaly. Back: Vertebral column deformities. Abdomen: Bowel sounds. History of Present Illness: Duration of chest pain. during exercise). frequency. dull). temperature. gynecomastia. Relationship of pain to activity (at rest. tenderness. breast development. dizziness? Dermatomal distribution? Aggravated by rising from supine position? Poor school attendance? Stressful life events? Physical Examination General: Visible pain. Past Medical History: Exercise tolerance. sharp. Chest: Chest wall tenderness. Laboratory Evaluation: Electrolyte. School function and atten­ dance. Family History: Heart disease. Heart: First and second heart sounds. cough. abdominal pain. splenomegaly. CBC. diabetes. Growth chart and percentiles. . smoking. Weight loss. ECGs. chest X-ray. recent losses or separations. limb pain. Medications: Aspirin. Elicit drugs. apprehension. character (squeezing. masses. fever. angina. eating).

peptic ulcer disease Vertebral/Radicular Disorders Spinal stenosis Herniated disk Vertebral fracture Dyspnea and Congestive Heart Failure Chief Complaint: Shortness of breath. foreign body aspiration. HEENT: Jugular venous distention. Note whether the patient looks “ill” or well. cough. S3 gallop. aggravating or relieving factors. furosemide. dyspnea. sudden). Differential Diagnosis: Heart failure. clubbing. gastroesophageal reflux. hyperventilation Breast Disorders: Gynecomastia. Feeding difficulty. growth deficiency. drug allergies. temperature. pneumonia. Past episodes. pulmonary edema). murmur. pulses. pneumothorax. ECGs. x-rays. diminished volume of feeding. hyperventilation. Abdomen: Hepatomegaly.14 Dyspnea and Congestive Heart Failure Differential Diagnosis of Chest Pain Musculoskeletal Disorders Costochondritis Chest wall syndrome Tietze syndrome Xiphoid cartilage syndrome Stitch Precordial catch syndrome Slipping rib syndrome Idiopathic Disorders: Psychogenic. pallor. Heart: Lateral displacement of point of maximal impulse. asthma. Physical Examination General Appearance: Respiratory distress. stridor. splenomegaly. fibrocystic changes Cardiovascular Disease Pericarditis Left ventricular outflow obstruction. tachypnea or diaphoresis with feedings. effusions. chest pain. asthma Gastrointestinal Disorders: Esophagitis. Laboratory Evaluation: O2 saturation. Medications: Bronchodilators. Past Treatment or Testing: Cardiac testing. hyperdynamic precordium. cyanosis. irregular. rhythm. asthma. fever. Chest: Intercostal retractions. crackles. S4. Poor weight gain. Vital Signs: BP (supine and upright). wheezing. dyspnea on exertion. chest x-ray (cardiomegaly. dullness to percussion. Past Medical History: Hypertension. prolonged feeding time. respiratory rate (tachypnea). pneumothorax. rhonchi. . Difficulty keeping up with peers during play. liver tenderness. growth percentiles. Extremities: Cool extremities. digoxin. aortic murmur Dysrhythmias Pulmonary Disorders: Pneumonia. diabetes. pulse (tachycardia). History of Present Illness: Rate of onset of dyspnea (gradual. edema.

corticosteroids. plethora (pheochromocytoma). palpitations (pheochromocytoma). enlarged kidney (polycystic kidney disease. aortic coarctation). 24 hour urine for metanephrine. webbing of the neck (Turner's syndrome. joint swelling. Medications Associated with Hypertension: Oral contraceptives. uric acid. Masses (pheochromocytoma. pheochromocytoma. enuresis. asymmetric. lipid profile. diaphoresis. ECG. Skin: Pallor (renal disease). Vital Signs: Tachycardia (hyperthyroidism). Chest X-ray: Cardiomegaly. pheochromocytoma). Growth delay. pulse. alcohol. hyperactivity. creatinine. Headaches. Chest: Crackles (pulmonary edema). Wilms' tumor). joint tenderness (connective tissue disease). pulsating aortic mass (aortic aneurysm). costovertebral angle tenderness. glucose. hypopigmented lesions (Von Recklinghausen's disease. Tremor (hyperthyroidism. tuberous sclerosis). Family History: Hypertension. buffalo hump (Cushing's syndrome). Social History: Tobacco. age of onset of hyperten­ sion. indentation of aorta (coarctation). UA with microscopic analysis (RBC casts. fever (connective tissue disorder). plasma catecholamines (pheochromocytoma). Physical Examination General Appearance: Confusion. increased appetite. Extremities: Edema (renal disease). umbilical artery/vein catheterization (renal artery stenosis). femoral bruits. flushing. neuroblastoma. agitation (hypertensive encephalopathy).Hypertension 15 Hypertension Chief Complaint: High blood pressure. Neurologic: Rapid return phase of deep tendon reflexes (hyperthyroidism). BP in all extremities. café au lait spots. . intercostal bruits (aortic coarctation). Abdomen: Bruit below costal margin (renal artery stenosis). abdominal pain (renal disease). rashes (connective tissue disease). History of Present Illness: Current blood pressure. renal disease. Laboratory Evaluation: Potassium. heat intolerance (hyperthyroidism). BUN. hydronephrosis). hirsutism (Cushing's syndrome). murmur. thyromegaly (hyperthyroidism). truncal obesity (Cushing's syndrome). nonsteroidal antiinflammatory drugs. HEENT: Papilledema. amphetamines. cocaine. dysuria. Echocardiogram. tremors. CBC. Past Medical History: Lead exposure. weight loss. proteinuria). striae. fevers. renal ultrasound. moon faces (Cushing's syndrome). Laterally displaced apical impulse (ventricular hypertrophy). nocturia. Heart: Delayed radial to femoral pulses (aortic coarctation). lymphedema (Turner's syndrome). preeclampsia. wheeze. Perinatal History: Neonatal course. rib notching. respiratory rate. vomiting (increased intracranial pressure). hematuria.

ganglioneuro­ blastoma.16 Hypertension Differential Diagnosis of Hypertension Renal Chronic pyelonephritis Chronic glomerulonephritis Hydronephrosis Congenital dysplastic kidney Multicystic kidney Solitary renal cyst Vesicoureteral reflux nephropathy Vascular Coarctation of the aorta Renal artery lesions Umbilical artery catheterization with thrombus formation Endocrine Hyperthyroidism Hyperparathyroidism Congenital adrenal hyperplasia Cushing syndrome Hyperaldosteronism Central Nervous System Intracranial mass Hemorrhage Essential Hypertension Low renin Normal renin High renin Brain injury Quadriplegia Pheochromocytoma Neuroblastoma. ganglioneuroma Diabetic nephropathy Liddle's syndrome Neurofibromatosis Renal vein thrombosis Vasculitis Segmental hypoplasia Ureteral obstruction Renal tumors Renal trauma Systemic lupus erythematosus (other connective tissue dis­ eases) .

. pulse (tachycardia). Pulmonary function tests. clubbing. hay fever. Chest X-ray: Hyperinflation. Nose: Nasal flaring. BP (widened pulse pressure). depth of respirations. intracostal retractions. fever. decreased breath sounds. Mouth: Pharyngeal erythema. elongated heart. allergies. anxiety. flattening of diaphragms. Skin: Flexural eczema. frequency of hospitalizations. Vital Signs: Peak expiratory flow rate (PEFR). urinalysis. grunting. edema. pulmonary function testing. rhonchi. Note whether the patient looks well. Perinatal History: Prematurity (bronchopulmonary dysplasia). Family History: Asthma. supraclavicular retractions. respiratory rate (tachypnea). History of Present Illness: Onset. Laboratory Evaluation: CBC. prolonged expiratory phase. cold air. Aggravating factors: Exercise. exposure to dust mites. current and baseline peak flow rate. food allergies. atopic dermatitis. perioral cyanosis. animal dander. Chest: Sternocleidomastoid muscle contractions. third heart sound (S3). Past Medical History: Previous episodes. small. electrolytes. paradoxical abdominal wall motion (abdomen rises on inspiration). increased intensity of pulmonic component of second heart sound (pulmonary hypertension). or somnolent. Heart: Distant heart sounds. tenderness. Temperature. chronic rhinitis. Abdomen: Retractions. Baseline arterial blood gas results. home nebulizer use. recurrent croup. Physical Examination General Appearance: Respiratory distress. hypoxia. Seasons that provoke symptoms. Expiratory wheeze. cough. pulsus paradoxus (>15 mmHg is significant pulmonary compro­ mise). pneumonia. nasal polyps. barrel chest. severity of attack compared to previous episodes. ill. duration and progression of wheezing. urticaria. Extremities: Cyanosis. viral or respiratory infections.Wheezing and Asthma 17 Pulmonary Disorders Wheezing and Asthma Chief Complaint: Wheezing. allergic rhinitis. pallor. ABG: Respiratory alkalosis. foreign body aspiration.

Hoarseness. Anxiety. worsening in the supine position. exposure to infections. hoarseness. . drooling. fever. sore throat. Historical Evaluation of Stridor and Oropharyngeal Obstruction Oropharyngeal Obstruction Fever. Perinatal History: Abnormal position in utero. shoulder dystocia. headache. Grunting respirations. forceps delivery. foreign body. Respiratory distress or stridor at birth. respiratory distress. improvement with the neck extended (congenital laryngomalacia). choking with feedings. obtundation. malaise. Trauma or previous surgery. headache Muffled voice Craniofacial anomalies Cutaneous abnormalities Neurologic symptoms Stridor Gradual onset Acute onset. sore throat. Increased stridor with stress. fever Worsens in supine position Perinatal trauma Method of delivery Present at birth Feeding difficulties Previous intubation Physical Examination General Appearance: Adequacy of oxygenation and ventilation. hemangiomas. Growth percentiles. Cough. muffled voice. regurgitation.18 Stridor and Oropharyngeal Obstruction Differential Diagnosis of Wheezing Infant Vascular ring Tracheoesophageal fistula Gastroesophageal reflux Asthma Viral infection (bronchiolitis. fatigue. drooling. shallow breathing. restlessness. cyanosis. Tachycardia. History of Present Illness: Time of onset of stridor. tachypnea. Vital Signs: Respiratory rate. upper respiratory tract infection) Pertussis Cystic fibrosis Bronchopulmonary dysplasia Congenital heart disease Older Child Asthma Aspiration (reflux. stridor. Voice changes (muffled voice). Fever. History of intubation (subglottic stenosis). Head: Congenital anomalies. foreign body) Epiglottitis Laryngotracheobronchitis (croup) Cystic fibrosis Hypersensitivity pneumonitis Tuberculosis Tumor Alpha1-antitrypsin deficiency Vocal cord dysfunction Stridor and Oropharyngeal Obstruction Chief Complaint: Difficulty breathing. Pulse oximetry. airway stability.

Extremities: Cyanosis. viral Uvulitis Peritonsillar abscess Retropharyngeal abscess Parapharyngeal abscess Hemangioma Lymphangioma Ranula Lymphoma Lymphosarcoma Rhabdomyosarcoma Fibrosarcoma Epidermoid carcinoma Adenoidal hypertrophy Palatal hypotonia Obesity . wheezes. Physical Examination Findings in Stridor and Oropharyngeal Obstruction Anxiety.Stridor and Oropharyngeal Obstruction 19 Skin: Perioral cyanosis. Symmetrical palate movement. lethargy Cyanosis Tachypnea Hyperpnea Shallow breaths Pulse oximeter <95 % Poor growth Clubbing Heart murmur Congenital head and neck anomalies Bifid uvula Enlarged tonsil(s) Neck mass Asymmetric chest expansion Retractions Increased anteroposterior chest diameter Accessory muscle use Mouth-breathing Grunting. Chest: Wall movement and symmetry. Neck: Masses. retractions. Mouth: Bifid uvula. moist stridor Stridor Asymmetric wheezes Neck extended Opisthotonic posture Torticollis Differential Diagnosis of Oropharyngeal Obstruction Micrognathia Pierre Robin syndrome Treacher Collins syndrome Macroglossia Down syndrome Beckwith-Wiedemann syndrome Lymphangioma Hemangioma Lingual thyroid Tonsillitis/hypertrophy: Bacterial. tenderness. fatigue. mid-line trachea. abnormal pulses. edema. movement in all directions. cleft palate. nasal flaring Muffled voice Hyponasal speech Hypernasal speech Low-pitched. clubbing. external fistulas. paradoxical abdominal wall motion (abdomen rises on inspiration). asymmetric blood pressures. Tongue symmetry. fluttering sound Aphonia Quiet. hyperresonance. Nose: Nasal flaring. tonsil symmetry. Abdomen: Retractions. accessory muscle use (severe obstruction). Brisk gag reflex. Heart: Murmurs. clubbing. nail cyanosis. masses. chest diameter.

sore throat. Arnold-Chiari malformation). asymmetric blood pressures. hypernasal speech. previous surgery. temperature. mid-line trachea. retropharyngeal abscess. shoulder dystocia. lymphangioma) Hoarseness Chief Complaint: Hoarseness. grunting. masses. movement in all directions. abnormal sounds/posture. trauma. torticollis. opisthotonic posture. Fever. hyperextended neck during delivery (excessive neck traction). respiratory distress.Respiratory distress or stridor at birth. tachypnea. exacerbating or relieving factors. thermal injury. masses or external fistulas. Mouth: Tongue symmetry. Neck: Congenital anomalies.20 Hoarseness Differential Diagnosis of Stridor Neonatal Laryngomalacia Subglottic stenosis Webs Laryngeal cysts Tracheal stenosis Tracheomalacia Tracheal cartilage ring defect Laryngeal/tracheal ring calcification Vascular ring Pulmonary sling Innominate artery tracheal compres­ sion Vocal cord paralysis (Arnold-Chiari malformation. Chest: Asymmetric chest expansion. gastric secretions) Older Child Oropharyngeal infection (peritonsillar abscess. duration of symptoms. recurrent laryngeal nerve injury) Tumor Trauma (intubation. nasal flaring. Trauma or previous surgery. Dandy-Walker cyst. accessory muscle use. neck extended. wheezes. upright posture. Cardiac: Murmurs. Past Medical History: Intubation (subglottic stenosis). tonsillitis) Viral infections (croup) Epiglottitis Bacterial tracheitis Aspirated/swallowed foreign body Tumor (hemangioma. upper respiratory tract infections. quiet. abnormal vocal fremitus. History of Present Illness: Age and time of onset. hyponasal speech. hemangiomas. Physical Examination General Appearance: Hoarseness. Extremities: Cyanosis. asymmetric wheezes. Neurologic disorders (hydrocephalus. prior episodes of croup. Perinatal History: Abnormal position in utero. enlarged tonsil(s). neck mass. Vital Signs: Respiratory rate (tachypnea). cleft palate. moist stridor. tachycardia. prolonged loud crying or screaming (vocal chord polyps or nodules). inspiratory stridor. increased anteroposterior chest diameter. biphasic stridor. Delayed growth parameters. rate of onset. muffled voice. Mouth-breathing. exposure to infections. bifid uvula. Cleft lip. . retractions. corrosive. clubbing.

Cornelia de Lange syndrome Conversion reaction . Farber disease Viral infection (laryngitis. intubation) Gaucher disease. nodules) Sicca syndromes Neoplasia (papilloma.Hoarseness 21 Differential Diagnosis of Hoarseness Neonatal Laryngomalacia Webs Subglottic stenosis Cystic lesions Excessive secretions (fistulas. mucopolysaccharidosis Williams syndrome. heman­ gioma) Trauma (postsurgical. croup) Older Child Postnasal drip Epiglottitis Recurrent voice abuse (cord polyps. hypocalcemia. lymphangioma) Cri du chat syndrome Vocal cord paralysis Vocal cord trauma Hypothyroidism. gastroesophageal reflux) Vascular tumors (hemangioma.

22 Hoarseness .

Icterus. flies or mosquitoes. Exposure to mononucleosis. travel history. Unusual or poorly prepared foods? Raw fish. sore throat. joint complaints. Review of Systems: Breaks in the skin (insect bites or stings). smoking. Family History: Familial Mediterranean fever. Allergies: Drug allergies. dysuria. Growth and weight percentiles. streptococcal disease. ear pain. hypertension (neuroblastoma. Onset. pallor. sputum. splinter hem­ orrhages. school absence? Localized pain? Fever pattern? Exposures or travel? Pets? Kitten exposure. vaginal discharge. nodules. periodicity. stool. Note whether the patient looks “ill” or well. vomiting. anticonvulsants. weight loss. Diarrhea. and throat cultures? Complete blood count? Inflammatory disorders usually lead to a rise in leukocyte count. Vital Signs: Temperature (fever curve). time of onset. Previous surgery or dental work. Historical Findings in Fever of Unknown Origin Skin breaks? Puncture or laceration. Past Medical History: Ill contacts. temperature curve. pulse (tachycardia). History of Present Illness: Degree of fever. . headache. skin breaks. bowel movements. night sweats. Skin: Rashes. Drugs? Any medication. respiratory rate (tachypnea). animal exposure. AIDS risk factors. exposure to other animals. recent dental procedure. Social History: Alcohol use. growth curve failure. Insect bites? Tick exposure. bone or joint pain. delayed capillary refill. petechia (septic emboli. cough. Heart murmur. meningococcemia). Tuberculin skin test with controls? Physical Examination General Appearance: Lethargy. abdominal pain. tuberculin skin testing. Hypotension (sepsis). Blood. exposure to tuberculosis or hepatitis. neck stiffness. rash. urine. bruises. cough. connec­ tive tissue disease. unpasteurized milk. weight loss. pheochromocytoma). Falling counts suggest a marrow process.Fever 23 Infectious Diseases Fever Chief Complaint: Fever. Review of systems? Rashes. Medications: Antibiotics. Screening laboratory procedures? Rise in sedimentation rate. toxic appearance. pattern of fever.

magnetic reso­ nance imaging. Extremities: Wounds. supraclavicular. IV catheter tenderness (phlebitis) joint or bone tender­ ness (septic arthritis). Osler's nodes. Chest: Dullness to percussion. enteric infection (Salmonella. foreign body Urinary tract infection Osteomyelitis Meningitis. Pustules. bronchiectasis. discharge. pharyngeal erythema. Ears: Tympanic membrane inflammation. Lymph Nodes: Cervical. exudate. furuncles. vertebral tenderness. crackles. liver tenderness. toxoplasmosis . Neck: Lymphadenopathy. hepatomegaly. occult blood. endocarditis. fissures. sinusitis Lower--pneumonia. brucellosis. abscesses. genital herpes lesions. papilledema. Eyes: Conjunctival erythema. rectal flocculence. Yersinia species). Janeway's lesions (endocarditis). Pelvic/Genitourinary: Cervical discharge. Abdomen: Masses. hepatitis. splenomegaly. adnexal masses. cat­ scratch disease. Lyme disease. leptospirosis. inguinal adenopathy. masses. pharyngitis. retinal hemorrhages. encephalitis Abdominal abscess. abdominal X-ray Differential Diagnosis of Fever Infectious Disease (50% of diagnoses) Localized Infection Respiratory tract Upper–rhinitis. appendicitis Generalized Infection Common--Epstein-Barr virus. masses. cytomegalovirus Unusual--tularemia. adnexal tenderness. fissures. axillary. Rectal: Perianal skin tags. right lower quadrant tenderness (appendicitis). tuberculosis. Clubbing. drains Chest x-ray Computed tomography. sinus tenderness. Breast: Tenderness. rhonchi. Q fever. anal ulcers (Crohn disease).24 Fever ecthyma gangrenosum (purpuric plaque of Pseudomonas). syphilis. including leukocyte differential and platelet count Electrolytes Arterial blood gases Blood urea nitrogen and creatinine Urinalysis INR. bronchitis. partial thromboplastin time. Mouth: Periodontitis. myocarditis). Heart: Murmurs (rheumatic fever. fibrinogen Serum lactate Cultures with antibiotic sensitivities Blood Urine Wound Sputum. suprapubic tenderness (urinary tract infection). cervical motion tenderness. decreased mobility. Laboratory Evaluation of Fever Complete blood count. Costovertebral angle tenderness. cellulitis. neck rigidity.

respiratory rate (tachypnea). prior radiographs. dehydration. Family History: Atopy. familial Mediterranean fever (serositis. fever. Sore throat. Nose: Nasal polyps. ear pain. Psychosocial History: Daycare or school attendance. tuberculin testing. Sputum color. Medications: Antibiotics Immunizations: H influenzae. congenital pneumonias. Borrelia infection. “pharyngitis with aphthous stomatitis” (Marshall syndrome). asthma. immunodeficiencies. frequency of cough. Timing of the cough. arthritis). inguinal lymphadenopathy Ears: Tympanic membrane erythema. Note whether the patient looks “ill” well. asthma. choking. bronchopulmonary dysplasia. quantity. "brassy" cough (tracheal or large airway origins). Review of Systems: General state of health. growth and development. Travel history. consistency. multiple vague complaints. Lymph Nodes: Cervical. Vital Signs: Temperature (fever). Exposure to other persons with cough. mixed connective tissue disease Neoplasia Lymphoreticular malignancies Sarcomas Inflammatory Bowel Disease Crohn disease Periodic Fever Recurrent viral infections Cyclic neutropenia. cyanosis. Skin: Eczema. height and weight percentiles. chest pain. vomiting. Behçet's disease. pulse (tachycar­ dia). Past Medical History: Previous hospitalizations. conjunctivitis. tuberculosis. cough characteristics. BP. tobacco smoke. rhinorrhea. familial dysautonomia Pseudo-fever of Unknown Origin: Prolonged low-grade fevers without findings on examination. cystic fibrosis. axillary. feeding history. Physical Examination General Appearance: Respiratory distress. hemoptysis. abnormal stools. stressors within the family. Cough that is most notable when attention is drawn to it (psychogenic cough). streptococcal immunization. Dry. . chronic pulmonary disease. headache. Allergies: Drug Allergies Perinatal History: Respiratory distress syndrome. normal laboratory tests Cough and Pneumonia Chief Complaint: Cough History of Present Illness: Duration of cough. urticaria. exposure to tuberculosis. neuromuscular weakness. Diabetes. school absences. recurrent infections.Cough and Pneumonia 25 Collagen/Connective Tissue Disorders Juvenile rheumatoid arthritis Kawasaki syndrome Systemic lupus Rheumatic fever Other: Vasculitis syndromes.

muscle tone and strength. WBC (>15. Chest: Chest wall deformities. Abdomen: Hepatomegaly. BUN. thyroid masses. endocarditis. pleural effusion. creatinine. gag reflex. air bronchograms. cultures and fluorescent antibody techniques for respiratory viruses. dullness to percussion. Neurologic: Decreased mental status. rhonchi. Differential Diagnosis of Cough by Age Infant Toddler/Young SchoolAge Viral infections Sinusitis Tuberculosis Gastroesophageal reflux Inhaled foreign body Desquamative interstitial pneumonitis Lymphocytic interstitial pneumonitis Asthma Cough-variant asthma Pollutants (cigarette smoke) Suppurative lung disease Cystic fibrosis Bronchiectasis Right middle lobe syn­ drome Ciliary dyskinesia syn­ dromes Older SchoolAge/Adolescent Asthma Recurrent viral infections Sinusitis Tuberculosis Mycoplasma Gastroesophageal reflux Psychogenic cough Cystic fibrosis Bronchiectasis Immunodeficiency Infections Viral/bacterial infections Tuberculosis Gastroesophageal re­ flux Anomalies Vascular ring Innominate artery com­ pression Tracheoesophageal fistula Pulmonary sequestra­ tion Subglottic stenosis Interstitial pneumonia Desquamative intersti­ tial pneumonitis Lymphocytic interstitial pneumonitis Asthma Cystic fibrosis Ciliary dyskinesia syn­ dromes Immunodeficiency . splenomegaly. Tuberculin skin test (PPD). Neck: Rigidity. unequal expansion. O2 saturation. electrolytes. tonsillar enlargement. swallowing coordination. Chest X-ray: Segmental consolidation. gallops. UA. pharyngeal erythema. wheezing. murmurs (rheumatic fever. Increased vocal fremitus. atelectasis. blood cultures.000 cells/dL).26 Cough and Pneumonia Throat: Pharyngeal cobblestone follicles. asymmetry. crackles. masses. bronchial breath sounds with decreased intensity. Extremities: Cyanosis. Sputum or deep tracheal aspirate for Gram's stain and culture. Laboratory Evaluation: CBC. masses. clubbing. Heart: Tachypnea. myocarditis).

Laboratory Evaluation: CBC. Abdomen: Masses. previous hospitalizations. Vital Signs: Temperature (fever). rub. Chest roentgenogram results. prior radiographs. Travel History: Travel to South America. Sputum color. Medications: Antihistamines. Differential Diagnosis: Atypical mycobacteria infection. supraclavicular. Chest: Increased vocal fremitus. low-income population. diabetes. abnormal stools. asthma. . steroids. Histological examination of lymph nodes. time of onset. headache. hemoptysis. segmental atelectasis. joint pain. neck stiffness. Past Medical History: Previous pneumonia. bronchial breath sounds with decreased intensity. chronic lung disease. pulse (tachycar­ dia). Neurologic: Mental status. Urban. Physical Examination General Appearance: Respiratory distress. hepatomegaly. cough.Tuberculosis 27 Tuberculosis Chief Complaint: Cough and fever. Extremities: Clubbing. liver. Increased percussion resonance. Note whether the patient looks “ill” or well. tenderness. BUN. steroid use. bone marrow biopsies. Stiff neck. consistency. Lymph Nodes: Lymphadenopathy (cervical. Diabetes. diarrhea. feeding history. Allergies: Drug allergies. AIDS risk factors. inguinal). BP. liver function tests. Past Medical History: Previous episodes of otitis media. axillary. recurrent infections. cyanosis. Tuberculosis. murmur. asthma. duration of cough. muscle tone and strength. fever. Otitis Media Chief Complaint: Ear pain. neuromuscular weakness. urticaria. HEENT: Tympanic membrane erythema. growth percentiles. sputum. neck stiffness. Review of Systems: General state of health. Southeast Asia. active pulmonary tuberculosis. Family History: Source case drug resistance. hilar node enlargement. rhonchi. Chest X-ray: Segmental consolidation. Cardiac: Distant heart sounds. immunosuppression. UA. early morning gastric aspirate to obtain swallowed sputum for acid-fast bacilli stain and culture. Prior treatment for tuberculosis. splenomegaly. edema. electrolytes. pneumonia. Skin: Rashes. growth and development. O2 saturation. sore throat. headache. Degree of fever. bone pain. pleura. Social History: Daycare or school attendance. chronic pulmonary disease. irritability. respiratory rate (tachypnea). creatinine. History of Present Illness: Ear pain. Exposure to tuberculosis. quantity. History of Present Illness: Tuberculin skin test (PPD) results. homeless. latent tuberculosis. India. fever. immunodeficiencies. crackles.

ear pain. tympanosclerosis. hepatomegaly. Family History: Streptococcal throat infections. hepatomegaly. pneumonia. otitis media with effusion. irritability. erythematous tympanic membrane. Pharyngitis Chief Complaint: Sore throat. Heart: Rate and rhythm. splenomegaly. Nose: Nasal discharge. Chest: Breath sounds. mastoiditis. Throat: Erythema. opacified. cough. Mouth: Foul breath. soft palate petechiae. rheumatic fever. . otitis externa. Ears: Tympanic membrane erythema. Nose: Mucosal erythema. abdominal pain. immunosuppression. murmurs. Nasal discharge. ulcers. cholesteatoma. pulse. Throat: Pharyngeal erythema. History of Present Illness: Sore throat. fever. retraction.28 Pharyngitis Allergies: Antibiotics. Past Medical History: Previous episodes of otitis media. blood pressure. Laboratory Evaluation: CBC. vesicles. poor visualization of landmarks. diabetes. headache. Physical Examination Ears: Bulging. erythema. past streptococcal pharyngitis. bulging. exudate. Abdomen: Tenderness (mesenteric adenitis). asthma. Tonsillar exudate. Family History: Recurrent ear infections. absent light reflex . scarlet fever. Abdomen: Tenderness. tympanocentesis. Skin: Rash ("sandpaper" feel. Vital Signs: Temperature (fever). cholesteatoma. respiratory rate. Lymph Nodes: Tender cervical adenopathy. scarlet fever). prior streptococcal pharyngitis. Allergies: Antibiotics. Physical Examination General Appearance: Note whether the patient appears well or toxic. electrolytes. Differential Diagnosis: Acute otitis media. decreased mobility with insufflation of air.

no rhinorrhea. tonsillar exudates. Rash with peni­ cillin. abdominal pain (mesenteric adenitis). often papulosquamous. tonsillar exudates. Rash. head­ ache. soft palate petechiae. scarlet fever). no cough. foul breath. Coxsackie A). herpangina. . Illness lasts more than 7-10 days (GABHS infection resolves within 7 days). atypical lymphocytes in peripheral smear. fatigue. hepato­ splenomegaly.Clinical Manifestations of Pharyngitis Group A streptococcus Age Generally 3 years or older Viral (other than EBV) Any age Epstein-Barr virus Over 5 yrs (especially late school age/adolescent) Any Indolent onset. no URI symptoms) Any Papular-vesicular lesions or tonsillar ulcers (eg. URI symptoms. lymphadenopathy. conjunctivitis (ie. Season Clinical Fall to spring Tender cervical adenopathy. rash ("sandpaper" feel.

Medications: Immunosuppressants. "hot potato voice. Stridor. decreased breath sounds. Chest: Stridor. Past Medical History: Immunosuppression. History of Present Illness: 3 to 7 years of age and an abrupt onset of high fever. Abdomen: Tenderness.30 Peritonsillar. “toxic” appearance. diabetes. dysphagia. Lymph Nodes: Cervical lymphadenopathy. severe sore throat. groups C and G streptococci. adenovirus." uvula pointing toward unaffected side (peritonsillar abscess). Peritonsillar. Refusal to swallow. Corynebacterium diphtheriae (gray exudate in the pharynx). asthma. Respiratory distress (sitting in tripod posture with neck extended). Chlamydia. Throat: Trismus. Past Medical History: Previous peritonsillar abscesses. Heart: Murmurs. Laboratory Evaluation: Lateral neck x-rays . Ill appearance. pharyngitis. rhonchi. quiet. Stridor. Medications: Immunosuppressants. Differential Diagnosis of Pharyngitis: Viruses (influenza. immunosuppression. Physical Examination General Appearance: Inspiratory stridor. Abdomen: Tenderness. Family History: Streptococcal pharyngitis. hepatomegaly. dysphagia. Epiglottitis Chief Complaint: Sore throat. Chest: Breath sounds. drooling. drooling. Extremities: Cyanosis. hoarse voice. History of Present Illness: Recent tonsillopharyngitis or URI. throat culture. pneumonia. rubs. apprehension. drooling. Allergies: Antibiotics. Laboratory Evaluation: Cultures of surgical drainage. Retropharyngeal or Parapharyngeal Abscess Chief Complaint: Throat pain. splenomegaly. Retropharyngeal or Parapharyngeal Abscess Laboratory Evaluation: Rapid antigen detection test. otitis media. drooling. Physical Examination General Appearance: Severe throat pain and dysphagia. Lateral neck X ray. splenomegaly. anterior pharyngeal wall displace­ ment (retropharyngeal abscess). EpsteinBarr virus). Heart: Murmurs. Vaccinations: Haemophilus influenza immunization.

Allergies: Aspirin. Comfortable at rest. "toxic" ap­ pearance. Restlessness. refusal to speak Improving croup that worsens. Skin: Pallor. Past Medical History: Prematurity. non-toxic appearance.Croup 31 Differential Diagnosis of Epiglottitis Epiglottitis Viral Laryngo­ tracheitis Low-grade fever. tenderness. stridor. food allergies. altered mental status. . Medications: Bronchodilators. nasal discharge. barky. respiratory distress syndrome. diminished breath sounds. Laboratory Evaluation: Anteroposterior neck radiographs: subglottic narrow­ ing. heart disease. barking cough. temperature (low-grade fever). blood pressure. drooling. prematurity. pulse oximetry. Past Medical History: Chronic pulmonary disease (ie. anaphylaxis. Physical Examination General Appearance: Low-grade fever. Chest: Inspiratory stridor. Oxygen saturation. spasmodic croup (recurrent allergic upper airway spasm). Abdomen: Retractions. eczema. dysphagia. bronchopulmonary dysplasia. Past Medical History: Immunosuppression. hayfever. seal-like cough. often at night. Vaccinations: Haemophilus influenza immunization. anterior neck tenderness: no drool­ ing Croup (Viral Laryngotracheobronchitis) Chief Complaint: Cough. high fever. acute croup. cyanosis. hoarse voice Bacterial Tracheitis High fever. paradoxical abdominal wall motion (abdomen rises on inspiration). bronchopulmonary dysplasia). History of Present Illness: Mild upper respiratory symptoms. pulse (tachycardia). Social History: Exposure to passive cigarette smoke. ("steeple sign"). History of Present Illness: Duration of wheezing. mild fever. immunocompromise. followed by sudden onset of a barking cough and hoarseness. foreign body aspiration. Medications: Antibiotics. coryza. retractions. Family History: Asthma. Bronchiolitis Chief Complaint: Wheezing. Differential Diagnosis: Epiglottitis. cough. tachypnea. congestion. Cold weather months. Vital Signs: Respirations (tachypnea).

vomiting. Ears: Tympanic membrane erythema. Family History: Exposure to H influenza or neisseria meningitis. Neck: Nuchal rigidity. Chest: Chest wall retractions. bacterial antigen screen (1­ 2 mL). BUN. pneumonia. respiratory rate (tachypnea). Vital Signs: Temperature (fever). Skin: Capillary refill. CBC with differential. crackles. Nose: Rhinorrhea Mouth: Flaring of the nostrils. flattened diaphragms. Heart: Murmurs. diminished air exchange. non-toxic. asthma. pulse (tachycardia). sickle cell disease. murmurs. anorexia. Social History: Home situation. recent upper respiratory infections. electrolytes. cough. labored respira­ tions. irritability (high-pitched cry). Perinatal History: Prematurity. congestive heart failure. . Meningitis Chief Complaint: Fever and lethargy. smears and cultures from purpuric lesions: cultures of stool. pulse oximetry. icterus. Laboratory Evaluation: CSF Tube 1 . Note whether the patient looks “ill. pulse. Laboratory Evaluation: CBC. patchy atelectasis. creatinine. blood pressure. sensory deficits. Vital Signs: Temperature (low-grade fever).” well. Heart: Rate of rhythm. Chest X-ray: Hyperinflation. Head: Bulging or sunken fontanelle. Travel history. endocarditis. Medications: Antibiotics. Electrolytes. headache.Glucose.Gram stain. joint fluid. Kernig's sign (flexing hip and extending knee elicits resistance). papilledema. protein (1-2 mL). Brudzinski's sign (neck flexion causes hip flexion). History of Present Illness: Duration and degree of fever. Abdomen: Paradoxical abdominal wall motion with respiration (ie. neck stiffness. pupil reactivity. blood cultures. Extremities: Splinter hemorrhages (endocarditis). culture and sensitivity. Neurologic: Altered mental status. petechia. Diabetes. wheeze. wheezing.Cell count and differential (1-2 mL). rashes. Differential Diagnosis: Foreign body aspiration. rash.32 Meningitis Physical Examination General Appearance: Comfortable appearing. or malnourished. obtundation. purpura (meningococcemia). CSF Tube 3 . Eyes: Extraocular movements. Physical Examination General Appearance: Level of consciousness. weakness. otitis media. lethargy. fine crackles on inspiration. abdomen collapses with each inspiration). Chest: Rhonchi. respirations. Past Medical History: Pneumonia. Nasopharyngeal washings for RSV antigen. aspiration syndromes (gastroesophageal reflux). CSF Tube 2 . respiratory distress. abscess. BP (hypotension). urine.

fever. ½-2/3 of blood glucose level Low. chills (pyelonephritis). fever. frequency (voiding repeatedly of small amounts). constipation. suprapubic pain. constipation. partially treated bac­ terial. sepsis. vomiting. diarrhea. Signs and Symptoms of UTIs in Different Age Groups Age Neo­ nate/infant Signs/Symptoms Hypothermia. irritability. irritability. vomiting. vomiting. malodorous urine. diarrhea. abnor­ mal voiding pattern. <½ of blood glucose Bacterial meningitis or tuberculous men­ ingitis Cloudy Elevated 50-1500 >100 WBC/mm3 predomi­ nantly neutro­ phils. toxo­ plasmosis Clear opal­ escent Elevated usually <500 20-40. Bacte­ ria present on Gram’s stain. 10-500 WBC with predomi­ nant lymphs Tuberculous. mal­ odorous urine Abdominal pain. History of Present Illness: Dysuria. failure to thrive. Urine culture results (suprapubic aspiration or urethral catheterization). par­ tially treated bacte­ rial meningitis.Urinary Tract Infection 33 purified protein derivative (PPD). low-back pain. syphilitic men­ ingitis. incontinence. Cerebral Spinal Fluid Analysis Disease Normal CSF Fluid Color Clear Protein <50 mg/100 mL Cells <5 lymphs/mm3 Glucose >40 mg/100 mL. en­ cephalitis. lethargy. malodorous urine. poor growth Toddler . meningeal metastases Viral meningitis. jaundice. fungal. hyperthermia. low Clear opal­ escent Slightly elevated or nor­ mal 10-500 WBC with predomi­ nant lymphs Normal to low Urinary Tract Infection Chief Complaint: Pain with urination. Past Medical History: Urinary infections.

nasal discharge. rash. pelvic inflamma­ tory disease. appendicitis. Differential Diagnosis of Urinary Tract Symptoms Urinary tract infection Urethritis Urethral irritation by soaps. urine C&S. foreskin. bubble bath Vaginal foreign bodies Emotional disturbances Vulvovaginitis Trauma (sexual abuse) Pinworms Lymphadenopathy and Lymphadenitis Chief Complaint: Swollen lymph nodes. renal nuclear scan. pyelonephritis. incontinence or secondary enuresis. Sore throat. relapsing fever. cough. Laboratory Evaluation: UA with micro. frequency. Animal exposure (cat scratch. vulvovaginitis. respiratory rate. herpes infection. travel history. Past Medical History: Developmental delay.34 Lymphadenopathy and Lymphadenitis Age School age Signs/Symptoms Dysuria. Chest: Breath sounds. electrolytes. septic appearance. Lower abdominal mass (distended bladder). recurrent infections. pulse. Abdomen: Suprapubic tenderness. nephromegaly. Conjunctivitis. . phimosis. blood product exposure. Heart: Rhythm. pattern. frequency. exposure to tuberculosis. voiding cystourethrogram. fever Adolescent Physical Examination General Appearance: Dehydration. growth failure. abdominal pain. Pelvic/Genitourinary: Circumcision. Fever. murmurs. abdominal pain. kittens). mal­ odorous urine. urine Gram stain. arthralgias. renal mass. urgency. Vital Signs: Temperature (high fever [>38°C] pyelonephritis). stool in colon. spiking fevers. cervicitis. constipation. fever Dysuria. vaginal discharge. Differential Diagnosis: Cystitis. Localized trauma or skin infection. Social History: Intravenous drug use. BP. Note whether the patient looks toxic or well. hypospadia. Ultrasound. malodor­ ous urine. costovertebral angle tenderness (pyelonephritis). high-risk sexual behavior. CBC with differential. History of Present Illness: Duration of generalized or regional adenopathy. deter­ gents. gonococcal or chlamydia urethritis. urgency.

fluctuation. Review of Systems: Weight loss. malar rash (systemic lupus erythematosus). bone pain. brisk reflexes Rash/exanthem Hepatosplenomegaly Skin pustule/puncture Conjunctivitis/uveitis Midline neck mass that retracts with tongue protrusion Mass in posterior triangle Supraclavicular mass . septic appearance. discreteness. Skin: Lesion in the area(s) drained by affected lymph nodes. Eyes: Conjunctivitis. Lymph Nodes: Generalized or regional adenopathy. Abdomen: Tenderness. Pallor. Heart: Rhythm. masses. Note whether the patient looks toxic or well.Lymphadenopathy and Lymphadenitis 35 Medications: Phenytoin. easy bruising. joint tenderness. punctums. wheeze. uveitis. wide pulse pressure. exanthems or enanthems. murmurs. Chest: Breath sounds. blood pressure. size of enlarged lymph nodes. Extremities: Joint swelling. Supraclavicular or posterior triangle lymphadenopathy. pustules. nasopharyngeal masses. extremity lesions. pulse (tachycardia). wide pulse pressure (hyperthyroidism). consistency. Location. Growth percentiles. crackles. Vital Signs: Temperature (fever). hepatomegaly splenomegaly. Historical Evaluation of Lymphadenopathy Generalized or regional adenopathy Fever Rash Exposure to infection Travel Animal exposure Blood product exposure Arthralgia/arthritis Delayed growth/development Weight loss. mobility. tenderness. Sandpaper rash (scarlet fever). Physical Examination Findings in Lymphadenopathy Generalized or regional adenopathy Growth failure Fever Tachycardia. night sweats Lesions at birth Physical Examination General Appearance: Dehydration. splinter hemorrhages (endocarditis). night sweats.

sporotrichosis Generalized infection (mononucleosis. rubella or rubeola) Epstein-Barr virus Cytomegalovirus Hepatitis virus Cat-scratch disease Mycoplasma organisms Bacterial endocarditis Immune-Mediated Inflammatory Systemic lupus erythematosus Juvenile rheumatoid arthritis Serum sickness Storage Diseases Tuberculosis Syphilis Toxoplasma organisms Brucella organisms Histoplasmosis Coccidioidomycosis Typhoid fever Malaria Chronic granulomatous disease HIV infection Disorders Kawasaki syndrome Hyper IgD syndrome Hyper IgE syndrome . immunodefi­ ciency Differential Diagnosis of Generalized Lymphadenopathy Systemic Infections Bacterial infections Scarlet fever Viral exanthems (eg. scalp infections (eg. mononucleosis. lower cervical Axillary Generalized adenopathy. toxoplasmosis. sarcoidosis Chronic granulomatous disease. tinea capitis) Oropharyngeal or facial infections (unilateral. tularemia Adjacent skin infection Kawasaki's disease. posterior/ suboccipital. inguinal Recurrent episodes of adenitis Cat scratch disease. occipital Submandibular. secondary syphilis Infiltrative process (malignancy) Preauricular Posterior cervical Bilateral cervical of marked degree Supraclavicular or scalene.36 Lymphadenopathy and Lymphadenitis Differential Diagnosis of Adenopathy Based on Location Location of Node(s) Posterior auricular. anterior cervi­ cal Etiology of Infection or Process Measles. immunodeficiency (HIV). epitrochlear. "cold" submandibular nodes without infection indicates atypical mycobacteria) Sinusitis. hepatitis). in­ cluding axillary.

after saline infusion. cancer. Review of Systems: Animal exposure (pets). for Gram's stain and acid-fast stains. Family History: Diabetes. . Physical Examination General Appearance: Note whether the patient looks “ill” or well. Blood cultures. headache. recent surgery. Needle aspiration of the node. VDRL. chills. Past Medical History: Cirrhosis. Fever. indurated lesion. toxoplasmosis titers. Differential Diagnosis of Cervical Lymphadenopathy Viral upper respiratory tract infection (EBV or CMV infection) Suppurative infections (staphylococcal. chest X ray. night sweats. painful. allopurinol) Hemolytic anemias Immunoblastic lymphadenopathy Tangier disease Histiocytosis X X-linked lymphoproliferative syndrome Adrenal insufficiency Sarcoidosis Sinus histiocytosis Laboratory Evaluation: Throat culture. anaerobes. CBC and differential. ESR. travel history. PPD. drug therapy. heart murmur. diarrhea. CMV. red. and culture for aerobes. AIDS risk factors. Social History: Home situation. History of Present Illness: Warm. EBV. Cat scratch bacillus (Bartonella henselae) titer. localized pain. Allergies: Drug allergies. diabetes. Insect bite or sting. and mycobacteria.Cellulitis 37 Gaucher disease Niemann-Pick disease Malignancies Leukemia Lymphoma Neuroblastoma Metabolic Disorders Hyperthyroidism Miscellaneous Drug reactions (phenytoin. joint pain. streptococcal) Cold inflammation Cat-scratch disease Atypical mycobacterial adenitis Toxoplasmosis Systemic disorders Kawasaki syndrome Kikuchi disease Hyper IgD syndrome Hyper IgE syndrome Sinus histiocytosis Sarcoidosis Drugs Cellulitis Chief Complaint: Red skin lesion.

murmur. blood cultures. UA. pulse (tachycardia). Eyes: Roth spots (white retinal patches with surrounding hemorrhage) Chest: Crackles. joint or bone tenderness (septic arthritis). temperature (fever). anorexia. sensory deficits. urinary tract infection. respirations (tachypnea). neck rigidity. weight loss. pulse (tachycardia). creatinine. splenomegaly. petechia. ecthyma gangrenosum (purpuric of Pseudomonas). abscesses. Laboratory Evaluation: CBC. glucose. Past Medical History: Congenital heart disease. BUN. BUN/creatinine.38 Infective Endocarditis Vital Signs: Temperature (fever curve). skin breaks. Skin: Petechiae. Heart: Murmurs (endocarditis). valvular disease. Antigen detection studies. Janeway lesions. tuberculosis. Abdomen: Liver tenderness. Chest: Rhonchi. hepatomegaly. stroke. BP (hypotension). Neurologic: Weakness. erysipelas. ESR. systemic infection. abdominal pain. tympanic membrane inflamma­ tion. skin lesion cultures. Needle aspiration of border for Gram's stain and culture. electrolytes. urinalysis and culture. tenderness. dermatophytosis. seizures. Vital Signs: Blood pressure (hypotension). indurated lesion. dullness to percussion (pneumonia). . urine Gram stain. splenomegaly. ECG. CXR. Extremities: Wounds. Abdomen: Hepatomegaly. rhonchi. respiratory rate (tachypnea). Lymph Nodes: Adenopathy localized or generalized lymphadenopathy. dental procedure. cultures of intravenous lines and catheter tips. C&S. periodontitis. echocardiography. rheumatic fever. blood cultures x 2. Differential Diagnosis: Cellulitis. Infective Endocarditis Chief Complaint: Fever History of Present Illness: Chronic fever. Differential Diagnosis: Infective endocarditis. Recent gastrointestinal procedure. suprapubic tenderness. Osler's nodes. ESR. Physical Examination General Appearance: Note whether the patient looks toxic or well. malaise. pustules. arthralgias. Laboratory Studies: CBC (leukocytosis with left shift). Skin: Warm. urinary procedure. splinter hemorrhages. Extremities: Edema. Heart: Regurgitant murmurs. HEENT: Conjunctival erythema. crackles. Bullae. Poorly demarcated erythema with flat borders. Costovertebral angle tenderness. clubbing. dermatitis. rheumatic fever. tender. erythematous.

or refusal to walk. sickle cell anemia. Vital Signs: Temperature (fever).000 <15. decreased range of motion. Acute onset of fever. M. mucin clot. Abdomen: Tenderness. glucose. Chest: Crackles. acute rheumatic fever. friction rub. periosteal reaction). cellulitis. Synovial Fluid Findings in Various Types of Arthritis WBC Count/mm3 % PMN Joint Fluid:Blood Glucose Ratio Decreased Normal to decreased Normal Septic arthritis Juvenile rheuma­ toid arthritis Lyme arthritis >50. systemic lupus erythematosus. swelling. Arthrocentesis for cell count. trauma.000 Differential Diagnosis: Septic arthritis. Blood cultures. swelling.Septic Arthritis 39 Septic Arthritis Chief Complaint: Joint pain. rhonchi. anti-streptolysin-O titer. Lyme disease. Preexisting joint disease (eg. Bone-joint scans (gallium. Vesicular rash. joint tenderness. dog or cat bite (Pasteurella multocida). Penetrating injuries or lacerations. sexually transmitted disease exposure. tuberculosis. juvenile rheumatoid arthritis. HEENT: Neck rigidity. Osteomyelitis Chief Complaint: Leg pain. abdominal pain. Laboratory Evaluation: X-rays of joint (joint space distention. Physical Examination General Appearance: Note whether the patient looks toxic or well. inflammatory bowel disease. penetrating trauma. human bites. History of Present Illness: Extremity pain. Gram's stain. Skin: Erythema. pulse (tachycardia). petechia. leukemia (bone pain). CT or MRI. degree of fever. synovitis.000-100. Lyme titer. cultures. technetium). blood pressure (hypotension). Past Medical History: H. rheumatoid arthritis). hepatomegaly. influenzae immunization. Refusal to change position. Hip pain. refusal to use the extremity or bear weight.000 �90 60 50+ 15. Heart: Murmurs. immunocompromise. prosthetic joint. Culture of cervix and urethra on Thayer-Martin media for gonorrhea. redness. skin puncture. limp. Extremities: Erythema. splenomegaly. limitation of extremity use. tuberculosis exposure. respirations. limitation in joint range of motion. History of Present Illness: Joint pain and warmth. duration of fever. .000-20.

CT or MRI. tibia.40 Osteomyelitis Past Medical History: Diabetes mellitus. rash. Feet: Puncture wounds. bone infarction (hemoglobinopathy). respirations (tachypnea). temperature (fever). Laboratory Evaluation: CBC (elevated WBC). rectal mass. sickle cell disease. blood culture. erythema. Social History: Intravenous drug abuse. Vital Signs: Blood pressure (hypotension). leukemia). Heart: Regurgitant murmurs. swelling. Extremities: Point tenderness. Back: Tenderness over spinus processes. surgery. cellulitis. Abdomen: Tenderness. thrombophlebitis. Chest: Crackles. Skin: Petechiae. ESR (>50). Physical Examination General Appearance: Note whether the patient looks septic or well. rhonchi. hemophilia with bleeding. Medications: Immunosuppressants. warmth. . child abuse/trauma. prosthetic devices. Differential Diagnosis: Cellulitis. synovitis. pulse (tachycardia). X-rays (soft tissue edema). skeletal or blood neoplasia (Ewing's sarcoma. Technetium bone scan. humerus. Tenderness of femur.

narcotics. Characteristics of last bowel movement. weakness. laxatives. fistulas. BP (hypertension. Signs of dehydration. anticholinergics. bloating. pus. weight gain. high-pitched rushes (early obstruction).or tension-related symptoms. femoral. Virchow node (supraclavicular mass). weight loss. liver texture (smooth. defecation. Past Medical History: Diabetes. (inguinal. Lymph Nodes: Cervical axillary. nausea. sore throat. costovertebral angle tenderness. retrocecal appendicitis. Iliopsoas Sign: Elevation of legs against examiner's hand causes pain. septic appearance. rashes. Social History: Recent travel. periumbilical. X-rays. blood. dull). body positioning to relieve pain. tenderness. inguinal lymphadenopathy. NSAIDs. fre­ quency. movement. distended bladder (obstructive uropathy). Skin: Jaundice. pulse (tachycardia). sharp. characteristics of pain (diffuse. prematurity. tympany. undigested food. pharyngeal erythema. emesis. Abdomen Inspection: Distention. distension.Acute Abdominal Pain and the Acute Abdomen 41 Gastrointestinal Disorders Acute Abdominal Pain and the Acute Abdomen Chief Complaint: Abdominal pain. respiratory rate and pattern (tachypnea). chills. peptic ulcer disease. Abdominal pain in family members. irritable bowel syndrome. constant or intermittent. Rovsing's Sign: Manual pressure and release at left lower quadrant causes referred pain at McBurney's point (appendicitis). diarrhea. Palpation: Masses. Family History. fatigue. gross or occult blood. Medications: Aspirin. anorexia. petechia. McBurney's Point Tenderness: Located two-thirds of the way between umbilicus and anterior superior iliac spine (appendicitis). Auscultation: Absent bowel sounds (late obstruction). hemorrhoids. vomiting (bilious. hypotension). Endoscopies. flat neck veins. What does the patient do when the pain occurs? Fever. melena. pallor. constipation. Perianal Examination: Fissures. urination. bruits. Percussion: Liver and spleen span. hepatomegaly. Obturator sign: Flexion of right thigh and external rotation of thigh causes pain in pelvic appendicitis. change in food consumption. burning. hernias. Relation to last menstrual period. hematochezia. Bimanual palpation of flank. soiling (fecal . nephromegaly. stress. Rebound tenderness. Rectal Examination: Impacted stool. nutritional status. crampy. masses. Review of Systems: Growth delay. drugs or alcohol. location of pain. splenomegaly. asthma. skin tags. Effect of eating. Physical Examination General Appearance: Degree of distress. coarse). umbilical). surgery. Headache. HEENT: Pale conjunctiva. Vitals: Temperature (fever). Relationship to meals. visible peristalsis (small bowel obstruction). Retained fecal material. History of Present Illness: Duration of pain.

42 Recurrent Abdominal Pain or urinary incontinence). Male Genital Examination: Hernias, undescended testes, hypospadias. Female Genital Examination: Urethra, distal vagina, trauma; imperforate hymen. Pelvic examination in pubertal girls. Cervical discharge, adnexal tenderness, masses, cervical motion tenderness. Extremities: Edema, digital clubbing. Neurologic: Observation of the patient moving on and off of the examination table. Gait. Laboratory Evaluation: CBC, electrolytes, liver function tests, amylase, lipase, UA, pregnancy test. Chest X-ray: Free air under diaphragm, infiltrates. Acute Abdomen X-ray Series: Flank stripe, subdiaphragmatic free air, distended loops of bowel, sentinel loop, air fluid levels, calcifications, fecaliths. Differential Diagnosis of Acute Abdominal Pain Generalized Pain: Intestinal obstruction, diabetic ketoacidosis, constipation, malrotation of the bowel, volvulus, sickle crisis, acute porphyria, musculoskeletal trauma, psychogenic pain. Epigastrium: Gastroesophageal reflux, intestinal obstruction, gastroenteritis, gastritis, peptic ulcer disease, esophagitis, pancreatitis, perforated viscus. Right Lower Quadrant: Appendicitis, intussusception, salpingitis, endometritis, endometriosis, ectopic pregnancy, hemorrhage or rupture of ovarian cyst, testicular torsion. Right Upper Quadrant: Appendicitis, cholecystitis, hepatitis, gastritis, gonococcal perihepatitis (Fitz-Hugh-Curtis syndrome), pneumonia. Left Upper Quadrant: Gastroesophageal reflux, peptic ulcer, gastritis, pneumonia, pancreatitis, volvulus, intussusception, sickle crisis. Left Lower Quadrant: Volvulus, intussusception, mesenteric lymphadenitis, intestinal obstruction, sickle crisis, colitis, strangulated hernia, testicular torsion, psychogenic pain, inflammatory bowel disease, gastroenteritis, pyelonephritis, salpingitis, ovarian cyst, ectopic pregnancy, endometriosis. Hypogastric/Pelvic: Cystitis, urolithiasis, appendicitis, pelvic inflammatory disease, ectopic pregnancy, strangulated hernia, endometriosis, ovarian cyst torsion, bladder distension.

Recurrent Abdominal Pain
Chief Complaint: Abdominal pain. History of Present Illness: Quality of pain (burning, crampy, sharp, dull); location (diffuse or localized). Duration of pain, change in frequency; constant or intermittent. Effect of eating, vomiting, defecation, urination, inspiration, movement and position. Characteristics of bowel movements. Relation to last menstrual period. Vomiting (bilious, undigested food, blood), constipation, diarrhea, hematochezia, melena; dysuria, hematuria, anorexia, weight loss. Rela­ tionship to meals; triggers and relievers of the pain (antacids). Relationship to the menstrual cycle. What does the patient do when the pain occurs? How does it affect activity? School attendance, school stress, school phobia. What fears does the child have? What activities has the child discontinued? Past Testing: Endoscopies, x-rays, upper GI series.

Recurrent Abdominal Pain 43 Past Medical History: Diabetes, asthma, surgery, diabetes, prematurity. Prior treatment for a abdominal pain. Family History: Abdominal pain in family members, urolithiasis, migraine, peptic ulcer disease, irritable bowel syndrome, hemolytic anemia, chronic pain. Social History: Recent travel, change in schools, change in water and food consumption, marital discord, recent losses (grandparent, pet), general family function. Review of a typical day, including meals, activities, sleep pattern, school schedule, time of bowel movements; drugs/alcohol, sexual activity, sexual abuse. Review of Systems: Growth, weight gain, stool pattern, bloating, distension, hematemesis, hematochezia, jaundice. Headache, limb pain, dizziness, fatigue, weakness. Stress- or tension-related symptoms. Physical Examination General Appearance: Degree of distress, septic appearance. Note whether the patient looks “ill” or well. Vitals: Temperature (fever), pulse (tachycardia), BP (hypertension, hypotension), respiratory rate (tachypnea). Growth percentiles, deceleration in growth, weight-for-height. Skin: Pallor, rashes, nodules, jaundice, purpura, petechia.
HEENT: Pale conjunctiva, scleral icterus.
Lymph Nodes: Cervical, periumbilical, inguinal lymphadenopathy, Virchow
node (enlarged supraclavicular node). Chest: Breath sounds, rhonchi, wheeze. Heart: Murmurs, distant heart sounds, peripheral pulses. Abdomen Inspection: Abdominal distention, scars, visible peristalsis. Auscultation: Quality and pattern of bowel sounds; high-pitched bowel sounds (partial obstruction), bruits. Palpation: Palpation while noting the patient's appearance, reaction, and distractibility. Tenderness, rebound, masses, hepatomegaly; liver texture (smooth, coarse), splenomegaly; retained fecal material. Bimanual palpation of flank (nephromegaly), hernias (inguinal, femoral, umbilical); costovertebral angle tenderness. McBurney's point tenderness: Located two thirds of the way between umbilicus and anterior superior iliac spine, appendicitis. Rovsing's sign: Manual pressure and release at left lower quadrant causes referred pain at McBurney's point, appendicitis. Percussion: Tympany, liver and spleen span by percussion. Perianal Examination: Fissures, fistulas, hemorrhoids, skin tags, underwear soiling (fecal or urinary incontinence). Rectal Examination: Impacted stool, masses, tenderness; gross or occult blood. Male Genital Examination: Hernias, undescended testes, hypospadias. Female Genital Examination: Hymeneal ring trauma, imperforate hymen, urethra, distal vagina. Pelvic examination in pubertal girls. Cervical discharge, adnexal tenderness, masses, cervical motion tenderness. Extremities: Brachial pulses, femoral pulses, edema. Digital clubbing, loss of nailbed angle (osteoarthropathy). Neurologic Examination: Observation of the patient moving on and off of the examination table; gait. Laboratory Evaluation: CBC, electrolytes, BUN, liver function tests, amylase,

44 Persistent Vomiting lipase, UA, pregnancy test. Chest X-ray: Free air under diaphragm, infiltrates. X-rays of Abdomen (acute abdomen series): Flank stripe, subdiaphragmatic free air, distended loops of bowel, air fluid levels, mass effects, calcifications, fecaliths. Differential Diagnosis of Recurrent Abdominal Pain Gastrointestinal Causes Antral gastritis, peptic ulcer Constipation Crohn disease Carbohydrate malabsorption Pancreatitis Cholelithiasis Malrotation and volvulus Intestinal parasitic infection (G. lamblia) Urinary Tract Disorders Ureteropelvic junction obstruction Urinary tract infection Urolithiasis Psychogenic Causes Conversion reaction Somatization disorder Anxiety disorder Other Causes Intervertebral disk disease Spine disease Musculoskeletal trauma Migraine or cyclic vomiting Abdominal epilepsy

Persistent Vomiting
Chief Complaint: Vomiting. History of Present Illness: Character of emesis (effortless, forceful, projectile, color, food, uncurdled milk, bilious, feculent, blood, coffee ground material); abdominal pain, retching, fever, headache, cough. Jaundice, recent change in medications. Ingestion of spoiled food; exposure to ill contacts. Overfeeding, weight and growth parameters, vigorous hand or finger sucking, maternal polyhydramnios. Wheezing, irritability, apnea. Emesis related to meals; specific foods that induce emesis (food allergy or intol­ erance to milk, soy, gluten). Pain on swallowing (odynophagia), difficulty swallowing (dysphagia). Diarrhea, constipation. Proper formula preparation, air gulping, postcibal handling. Constant headache, worse with Valsalva maneuver and occurring with morning emesis (increased ICP). Possibility of pregnancy (last menstrual period, contraception, sexual history). Prior X-rays, upper GI series, endoscopy. Past Medical History: Diabetes, peptic ulcer, CNS disease. Travel, animal or pet exposure. Medications: Digoxin, theophylline, chemotherapy, anticholinergics, morphine, ergotamines, oral contraceptives, progesterone, erythromycin. Family History: Migraine headaches.

animal/pet exposure Ill family members Stress Physical Examination General Appearance: Signs of dehydration. splenomegaly. masses. coffee-grounds Character of Emetic Act Effortless. Extremities: Edema. respiratory rate. Neurologic Examination: Strength. . Genitourinary: Adnexal tenderness. ketone odor on breath (apple odor. temperature (fever). electrolytes. pregnancy test. hypertension). short stature. localized tenderness. papilledema. gait. seizures. rash. increased bowel sounds. gagging Projectile vomiting Timing of Emesis Early morning Related to meals or foods Other Gastrointestinal Symptoms Nausea Swallowing difficulties Constipation Pain Jaundice Neurologic Symptoms Headache Seizures General Respiratory distress Travel. abdominal X-ray series. Growth percentiles. uterine enlargement. costovertebral angle tenderness. Vital Signs: BP (hypotension. diabetic ketoacidosis). nonbilious Tongue thrusting Finger sucking. hy­ pertension. Abdomen: Tenderness to percussion. rhonchi. Lungs: Wheezes. jugular venous distention. sensation. jaundice. rebound tenderness (peritonitis). fever. HEENT: Nystagmus. lipase. flushing. deep tendon reflexes. hypotension. distention. tachypnea. rales. pneumo­ nia Neurologic: Migraine. Physical Examination Findings in Persistent Vomiting Vital Signs: Tachycardia. masses. Rectal: Perirectal lesions. food Bile Feculent emesis Bloody. Note whether the patient looks “ill” or well. hepatomegaly. papilledema. pulse (tachycardia). amylase. LFTs. bilious Uncurdled milk. poor weight gain Abdomen Distension Absent bowel sounds Increased bowel sounds Rebound tenderness Masses Genitourinary System Adnexal pain Mass Rectal mass Respiratory: Bronchospasm. posture. Skin: Pallor. occult blood. Nephromegaly. cyanosis. Bulging fontanelle. purpura Laboratory Evaluation: CBC. UA. bradycardia. septic appearance. in­ creased intracranial pressure Renal: Flank pain Skin: Rash.Persistent Vomiting 45 Historical Findings in Persistent Vomiting Appearance of Vomitus Large volume.

disorders of carbohydrate metabolism. tetany. aminoacidopathies. stenosis. vascular ring. subdural hydrocephalus. caffeine. hepatitis. digoxin Blood: Swallowed maternal blood. congenital adrenal hyperplasia. GI perforation. lactobeazor. milk-soy protein intolerance. pancreatitis Neurologic: Increased intracranial pressure. kernicterus Renal: Obstructive uropathy. congenital lactose intolerance. hypercalcemia Drugs/toxins: Theophylline. gastritis. ulcers Pneumonia Dysautonomia Postoperative anesthesia . pyelonephritis Metabolic: Urea cycle deficiencies. stenosis. tracheal esophageal fistula. acidosis. edema. achalasia.46 Persistent Vomiting Differential Diagnosis of Vomiting in Infants Under 2 Weeks of Age Functional Innocent vomiting Gastroesophageal reflux Postcibal handling Improper formula preparation Aerophagia Gastrointestinal Obstruction Esophageal: obstruction atresia. cricopharyngeal incoordination. natal hernia. postoperative. diaphragmatic hernia Torsion of the stomach Malrotation of the bowel Volvulus Intestinal atresia. hypokalemia) Hirschsprung disease Imperforate anus Enteric duplication Other gastrointestinal causes: Necrotizing enterocolitis. meconium ileus with cystic fibrosis. renal insufficiency Infection: Systemic infections. meconium plug Webs Annular pancreas Paralytic ileus (peritonitis. acute infection.

disorder of carbohydrate metabolism. intestinal duplications Other gastrointestinal causes: Annular pancreas. malrotation. ipecac Blood Hydrometrocolpos Radiation/chemotherapy Reye syndrome Psychogenic vomiting Munchausen syndrome by proxy . congenital adrenal hyperplasia.Persistent Vomiting 47 Differential Diagnosis of Vomiting in Infants 2 Weeks to 12 Months of Age Gastroesophageal reflux. digoxin. pyloric stenosis. cholecystitis. incarcerated hernia. milk-soy protein intolerance. vascular ring. renal insufficiency. infection. hiatal hernia Stomach: Bezoar. sepsis. Meckel diverticulitis. acidosis. pseudo-obstruction Neurologic: Increased intracranial (subdural hematoma. hydrocephalus. peritonitis. pertussis. cerebral edema) Renal: Obstructive uropathy. intussusception. tetany. pancreatitis. paralytic ileus. lactose intolerance. stenosis. appendicitis. achalasia. pyelonephritis. otitis media. lactobeazor Intestinal obstruction. aminoacidopathies. celiac disease. stones Infectious: Meningitis. hypercalcemia Drugs/toxins: Theophylline. hypokalemia. Hirschsprung disease. esophagitis Functional Innocent Improper formula preparation Aerophagia Postcibal handling Nervous Rumination Esophageal: Foreign body. parasitic infestation Metabolic: Urea cycle deficiencies. sinusitis. tracheoesophageal fistula cricopharyngeal incoordination. gallstones. iron. hepatitis. Helicobacter sp. viral and bacterial enteritis.

celiac disease. malrotation. paralytic ileus. ipecac. alcohol. pyelonephritis. digoxin. Inability to pass meconium (cystic fibrosis). Newborn hypoglycemia. lethargy after the first formula feedings (carbohydrate metabolic disorders). Past Medical History: Hepatitis serologies. alpha1-antitrypsin deficiency. raw shellfish. History of Present Illness: Timing. foreign travel. hepatobiliary disease. streptococcal pharyngitis. Helicobacter pylori infection. otitis media. volvulus. blood products. seizures Renal: Obstructive uropathy. Social History: IV drug abuse. arthralgias. Meckel diverticulitis. elicit drugs Torsion of the testis or ovary Blood Radiation/chemotherapy Reye syndrome Postoperative vomiting Cyclic vomiting Pregnancy Psychologic: Bulimia nervosa. foreign body. anorexia nervosa. adrenal insufficiency Drugs/toxins: Aspirin. Medications: Acetaminophen. medications taken during the pregnancy. bezoar. lung disease. pancreatitis. ulcerative colitis. liver biopsy. caudal progression of jaundice (physiologic jaundice or breast-feeding jaundice). renal insufficiency. stones Infection: Meningitis. History of perinatal infant death (metabolic disorders). intussusception. motion sickness. exposure to hepatitis. diabetic ketoacidosis. phenytoin. Leigh disease. Crohn disease. Family History: Liver disease. isoniazid. stress. pruritus. gallstone ileus. acidosis. distribution of jaundice. vomiting. rash. Perinatal History: Course of the pregnancy. hypokalemia. Henoch-Schönlein purpura. labyrinthitis Metabolic: Inborn errors of metabolism. day care centers. irritability. Neurologic: Increased intracranial pressure. corrosive ingestion. hiatal hernia Stomach: Foreign body. sepsis. fever. lead. superior mesenteric artery syndrome Other gastrointestinal causes: Annular pancreas. hepatitis immunization. progression. Hirschsprung disease. diarrhea. dark urine. intramural hematoma. Gradual. liver function tests. familial jaundice.48 Jaundice and Hepatitis Differential Diagnosis of Vomiting in Children Older Than 12 Months of Age Gastroesophageal reflux Gastrointestinal obstruction Esophagea: Esophagitis. illnesses. meconium ileus in cystic fibrosis. parasitic infestation. iron. sinusitis. Munchausen syndrome by proxy Jaundice and Hepatitis Chief Complaint: Jaundice. . incarcerated hernia. anorexia. viral or bacterial enteritis. Abdominal pain. chronic granulomatous disease Intestinal obstruction: Pyloric channel ulcer. hepatitis. peritonitis. infections. failure to thrive. migraine.

albumin levels INR. BP. hypertelorism. Note whether the patient looks “ill” or well. travel. Rectal: Perianal skin tags (inflammatory bowel disease). Lymph Nodes: Cervical or inguinal lymphadenopathy. Vital Signs: Pulse. smear AST. excoriations. leth­ argy with feedings. firm. icterus.Jaundice and Hepatitis 49 Historical Findings in Jaundice Neonate Family history: Familial jaundice. Malar rash. Wilson's disease). Jaundice. anasarca. infant deaths Prenatal history: Infection in pregnancy. GGT. large fontanelle. diffuse rash (perinatal infection). erythematous nodules over shins (erythema nodosum). irregular. smooth). bruits. hemorrhoids. Older Child Acute illness Failure to thrive Family history of jaundice Exposure: Blood products. microcephaly. Neurologic: Lethargy. Mouth: Sublingual jaundice. septic appearance. Eyes: Scleral icterus. differential. palmar erythema. Heart: Rhythm. platelets. occult blood. irritability. cataracts. hypotonia. right upper quadrant tenderness. murmurs. xanthomas (chronic liver disease). respiratory rate. medications Perinatal history: Hypoglycemia. neuromuscular deficits. pursed lips (Zellweger syndrome). acholic stools. Chest: Gynecomastia. discord lesions (lupus). joint swelling. splenomegaly. failure to pass meconium. emphysema. jaundice. vomiting. high forehead. Skin: Ecchymoses. Laboratory Evaluation of Jaundice Screening Labs Complete blood count. edema. temperature (fever). raw shellfish. erythematous scaling papules (cystic fibrosis). maternal risk for hepatitis. Extremities: Joint tenderness. ALT. urticaria. alkaline phosphatase Total and fractionated bilirubin Protein. hepatomegaly. liver span. Kayser-Fleischer rings (bronze corneal pigmentation. ascites. drug abuse Physical Examination General Appearance: Signs of dehydration. PTT Stool color . bronze discoloration (hemochromatosis). Head: Cephalohematoma. liver margin texture (blunt. Abdomen: Bowel sounds. breath sounds.

hemoglobinopathies. urine. Epstein-Barr virus Metabolic Alpha1-antitrypsin level and Pi typing Thyroxine and thyroid stimulating hormone Metabolic screen: Urine/serum amino acids Sweat chloride test Ceruloplasmin. cytomegalovirus. rubella.50 Jaundice and Hepatitis Assessment Labs Infection Cultures of blood. hepatitis panel. hemolytic anemias) . urinary copper excretion Toxicology screen Structural 24-hour duodenal intubation for bilirubin excretion Ultrasound Radionuclide or hepatobiliary scan Operative cholangiogram Autoimmune/inflammatory: ESR. herpes. ANA Pathologic Diagnosis Liver biopsy Bone marrow biopsy (enzyme deficiency. cerebrospinal fluid Serologies: Toxoplasmosis. syphilis.

cytomegalovirus. 21 Total parenteral nutrition Postoperative jaundice Extracorporeal membrane oxygena­ tion Idiopathic neonatal hepatitis . acidosis Hypoglycemia Maternal diabetes mellitus High intestinal obstruction Drugs Fatty acids (hyperalimentation) Lucy-Driscoll syndrome Conjugated hyperbilirubinemia Anatomic Extrahepatic Biliary atresia Bile duct stenosis Choledochal cyst Bile duct perforation Biliary sludge Biliary stone or neoplasm Intrahepatic Alagille syndrome Nonsyndromic interlobular ductal hypoplasia Caroli disease Congenital hepatic fibrosis Inspissated bile Conjugated hyperbilirubinemia (con­ tinued) Metabolic/genetic Alpha -antitrypsin deficiency 1 Galactosemia Fructose intolerance Glycogen storage disease Tyrosinemia Zellweger syndrome Cystic fibrosis Excretory defects Dubin-Johnson syndrome Rotor syndrome Summerskill syndrome Byler disease Infections TORCH (toxoplasmosis. D. 18. B. and E) Echovirus Tuberculosis Gram-negative infections Listeria monocytogenes Staphylococcus aureus Sepsis. urinary tract infection Hypoxia. urinary tract infections Miscellaneous Trisomies 17. herpes simplex) Syphilis HIV Varicella-zoster virus Coxsackievirus Hepatitis (A. other agents. rubella. C.Jaundice and Hepatitis 51 Differential Diagnosis of Neonatal Jaundice Nonpathologic Causes Physiologic jaundice Breast milk jaundice Pathologic Causes Unconjugated hyperbilirubinemia Bilirubin overproduction ABO/Rh incompatibility Hemoglobinopathies Erythrocyte membrane defects Polycythemia Extravascular blood Increased uptake Increased enterohepatic uptake Intestinal obstruction Genetic Crigler-Najjar types I and II Gilbert syndrome Miscellaneous Hypothyroidism Sepsis.

Coarsening of facial features (mucopolysaccharidoses). Vital Signs: Blood pressure. E). B. bruising (malignancy. Abdomen: Distension. bruising.52 Hepatosplenomegaly Differential Diagnosis of Jaundice in Older Children Metabolic/Genetic Gilbert syndrome Dubin-Johnson syndrome Rotor syndrome Cystic fibrosis Indian childhood cirrhosis Wilson disease Tyrosinemia Alpha -antitrypsin deficiency Infections (continued) Viral Herpes simplex virus Varicella-zoster virus Adenovirus Enterovirus Rubella virus Arbovirus HIV Echovirus Bacterial Sepsis Toxic shock syndrome Lyme disease Rocky mountain spotted fever Miscellaneous Visceral larval migrans Schistosomiasis Reye syndrome 1 Anatomic Caroli disease Congenital hepatic fibrosis Choledochal cyst Cholelithiasis Pancreas and pancreatic duct abnormalities Infections Viral Hepatitis (A. wheeze. metabolic disorders. Kayser- Fleischer rings (Wilson disease). petechiae. History of neonatal death. Lymph Nodes: Location and size of lymphadenopathy. bruits. weight loss. HEENT: Head size and shape. neurologic symptoms. cataracts (galactosemia). Liver span by . toxin. D. Perinatal History: Prenatal complications. C. Nutritional history. ill appearance. joint stiffness. History of Present Illness: Duration of enlargement of the liver or spleen. pallor. Acute or chronic illness. sarcoidosis). fatigue. toxins. Physical Examination General Appearance: Wasting. jaundice. Percussion of flanks for shifting dullness. Past Medical History: Previous organomegaly. pallor. alpha1­ antitrypsin deficiency. hepatic fibrosis. General health. prominent superficial veins (portal hypertension). CMV Epstein-Barr virus Hepatosplenomegaly Chief Complaint: Liver or spleen enlarged. Neurodevelopmental delay or loss of developmental milestones. Social History: Infections. neonatal jaundice. Growth curve. anticonvulsants. temperature. icterus. growth delay. exposures. drugs or alcohol. bilary obstruction of the biliary tract). spider angiomas (chronic liver disease. fever. joint pain. rhonchi. umbili­ cal hernia. respirations. Lungs: Crackles. erythema nodosum (inflammatory bowel disease. malnutrition. pulse. Skin: Excoriations. chronic liver disease). Family History: Storage diseases. Medications: Current and past drugs.

Hepatosplenomegaly 53 percussion. syphilis. hemangiomas. shunt infec­ tion Protozoal--malaria. rashes Head--microcephaly or macrocephaly Eyes--cataracts (galactosemia). alco­ hol. joint tenderness. hemochromatosis Fatty change: Malnutrition. rub. Rectal Exam: Masses. B. pruritus. myelofibrosis Vascular Portal vein anomalies Hepatic scarring or fibrosis Tumor and infiltration Cysts. Extremities: Edema. large kidneys. prominent veins. skin tags. tenderness. phenytoin Sclerosing cholangitis. parvovirus B19 Bacterial--endocarditis. fistulas. corticosteroids. intestinal disorders. petechiae and bruises. infectious cholangitis Abscess Chronic active hepatitis Cardiac--failure. tremor. joint swelling. pericarditis Budd-Chiari syndrome Paroxysmal nocturnal hemoglobinuria Biliary atresia or hypoplasia Choledochal cyst Congenital hepatic fibrosis Child abuse--trauma Galactosemia. tachycardia. joint erythema (juvenile rheumatoid arthritis. splenomegaly. pallor. Spleen size and texture. urea cycle disorders Cystic fibrosis Alpha -antitrypsin deficiency 1 Wilson disease. fistulas (inflammatory bowel disease). diabetes Primary or metastatic tumors . hamartomas Lymphoreticular malignancies Neuroblastoma Predominant Hepatomegaly CMV. fructose intolerance Tyrosinemia. mucopolysaccharidoses). hepatic disorders). babesiosis Hematologic Hemolytic anemias Porphyrias Osteopetrosis. sphincter tone. neonatal hepatitis Hepatitis--A. fissures. sarcoidosis. dystonia. spider nevi.developmental delay. absent reflexes. cytomegalovirus. fissures. glycogen storage disease. hepatosplenomegaly Rectal--hemorrhoids. obesity. hepatomegaly. chronic granulomatous dis­ ease Drugs--alcohol. edema. pulsus paradoxus Abdomen--ascites. skin tags with inflammatory bowel disease Neurologic-. ataxia Differential Diagnosis of Hepatosplenomegaly Predominant Splenomegaly Infection Viral–Epstein-Barr. Liver consistency and texture. D. C. Clubbing (hypoxia. tuberculosis. Physical Examination Findings in Hepatosplenomegaly Growth curve failure Skin: Icterus. E. Perianal: Hemorrhoids (portal hypertension). Kayser-Fleischer rings (Wilson disease) Nodes--generalized lymphadenopathy Chest--adventitious sounds Heart--gallop.

Volume of stool output (number of stools per day). CBC with differential. gallops. HEENT: Dry mucous membranes. number of stools per day. shellfish. weight loss. Ill contacts with diarrhea. Stool cultures for cholera. Norwalk virus. traveler's diarrhea. pulse (tachycardia). edema. stool for ova and parasites x 3. Stool occult blood. Immunizations: Rotavirus immunization. murmurs. foul odor).54 Acute Diarrhea Acute Diarrhea Chief Complaint: Diarrhea. fever. vomiting. rotavirus assay. anorexia. History of Present Illness: Duration. Past Medical History: Pattern of stooling from birth. sexual exposures. tempera­ ture (fever). foul odor. Vital Signs: BP( hypotension). high-pitched rushes. coli 0157:H7. Prior dietary manipulations and their effect on stooling. Yersinia. oily. Effect of fasting on diarrhea. inflammatory bowel disease. Vibrio parahaemolyticus). Exacerbation by stress. Bacillus cereus. anorexia. Gram's stain of stool for leukocytes. splenomegaly. characteristics of stools (bloody. Growth deficiency. formed. E. Past Medical History: Recent ingestion of spoiled poultry (salmonella). Rectal: Sphincter tone. hepatomegaly. laxative abuse. rashes. Travel history. Heart: Rhythm. well. AIDS risk factors. Extremities: Joint swelling. guaiac test. spoiled milk. seafood (shrimp. E coli. laxatives. Stool Appearance: Watery. Laboratory Evaluation: Electrolytes. Note whether the patient looks septic. History of Present Illness: Duration and frequency. blood or mucus. Sexual exposures. Cultures for enteric pathogens. Differential Diagnosis of Acute Diarrhea: Rotavirus. or malnourished. oily. Skin: Turgor. fever. Chronic Diarrhea Chief Complaint: Diarrhea. abdominal pain or cramps. shigella. Chest: Breath sounds. weight . Physical Examination General Appearance: Signs of dehydration. flatulence. myalgias. of diarrhea. Season (rotavirus occurs in the winter). Amount of fluid intake and food intake. delayed capillary refill. respiratory rate. travel history. tenesmus (painful urge to defecate). antibiotics. common food sources (restaurants). Medications Associated with Diarrhea: Magnesium-containing antacids. Formula changes. salmo­ nella. arthralgias. blood cultures. formed. mucus. abdominal pain. Campylobacter. stool and blood for clostridium difficile toxin. watery. antibiotic-related diarrhea. vomiting. Family History: Coeliac disease. frequency. and timing of diarrheal episodes. tenderness. jaundice. flatulence. Abdomen: Distention.

Medications and Substances Associated with Diarrhea: Laxatives. pallor (anemia).Chronic Diarrhea 55 gain. tempera­ ture (fever). decreased perianal sensation. glossitis (B12. sanitation. diminished deep tendon reflexes. dependent edema. decreased proprioception. Mouth: Oral ulcers (Crohn disease. adenopathy. Social History: Water supply. watery diarrhea Osmotic symptoms: Large numbers of soft stools Systemic symptoms: Fever. coeliac disease. tenderness. or inborn errors Secretory symptoms: Large volume. palpable stool. Perianal Examination: Skin tags and fistulas. or malnourished. Three-day dietary record. Neurologic: Mental status changes. Skin: Turgor. delayed capillary refill. meal preparation. folate deficiency). riboflavin deficiency).” well. Note whether the patient looks “ill. masses. peripheral neuropathy (B6. milk (lactase deficiency). neuroblastoma. meta­ bolic. Eyes: Bitot spots (vitamin A deficiency). pulse (tachycardia). palpable bowel loops. axillary. maculopapular rashes (inflammatory bowel disease). wheezing. masses. rashes. malaise Physical Examination General Appearance: Signs of dehydration or malnutrition. Abdomen: Distention (malnutrition). crackles. pyoderma gangrenosum. erythema nodosum. cholinergic agents. dehydration). pet or animal exposures. oropharyngeal candidiasis (AIDS). nausea. genetic. jaundice. Chest: Thoracic shape. Vital Signs: Growth percentiles. Hepatomegaly. hyperactive. hair thinning. magnesium-containing antacids. respiratory rate. bowel sounds. ill contacts. . Ataxia. hypotension. B12 deficiency). dry mucous membranes. Historical Findings in Chronic Diarrhea Age of onset Stool characteristics Diet (new food/formula) Growth delay Family history of allergy. splenomegaly. hyperpigmentation (adrenal insufficiency). tenderness. sphincter reflex. Septic appearance. inguinal lymphadenopathy. impacted stool. swelling (ulcerative colitis). gum (sorbitol). cheilosis (cracked lips. occult blood. Lymph Nodes: Cervical. Family History: Family members with diarrhea. Extremities: Joint tenderness. gluteal wasting (malnutrition). coeliac disease). sphincter tone. blood pressure (hypertension. Genitalia: Signs of child abuse or sexual activity. milk intolerance. Rectal: Perianal or rectal ulcers.

neutral fat (maldigestion). cultures for enteric pathogens. Stool carbohydrate content. CBC with differential. Stool for occult blood. ova and parasites x 3.56 Chronic Diarrhea Physical Examination Findings in Chronic Diarrhea Poor growth Hypertension Fever Jaundice Rash Erythema nodosum Pyoderma gangrenosa Edema Clubbing Lung crackles. wheezing Abdominal mass Organomegaly Abnormal genitalia Perianal tags Rectal impaction Ataxia. decreased deep tendon reflexes Laboratory Evaluation: Electrolytes. split fat (malabsorption). clostridium difficile toxin. Wright's stain for fecal leucocytes. Differential Diagnosis of Chronic Diarrhea Small Infants and Babies Chronic nonspecific diarrhea of infancy/postinfectious diarrhea Milk and soy protein intolerance Protracted infectious enteritis Microvillous inclusion disease Celiac disease Hirschsprung's disease Congenital transport defects Nutrient malabsorption Munchausen's syndrome by proxy Toddlers Chronic nonspecific diarrhea Protracted viral enteritis Giardiasis Sucrase isomaltase deficiency Tumors (secretotory diarrhea) Celiac disease Ulcerative colitis School-Aged Children Inflammatory bowel disease Appendiceal abscess Lactase deficiency Constipation with encopresis Laxative abuse Giardiasis .

Physical Examination General Appearance: Dehydration or malnutrition. joint swelling (ulcerative colitis). or malnourished. Neurologic: Developmental delay. iron supplements. mental retardation. weak cry. bulky. Encopresis. masses. Medications Associated with Constipation: Opiate analgesics. hemorrhoids. tenderness. poor growth. calcium. Palpable stool. Note whether the patient looks “ill. Growth percentiles. Dehydration. ex­ coriation. weak abdominal musculature (muscular dystrophy. decreased perianal sensation. peristaltic waves. Perianal: Anterior ectopic anus. temperature. B12 deficiency). Anal fissures. antidepressants. History of Present Illness: Stool frequency. Septic appearance. tenderness. dry mucous membranes. Skin: Café au lait spots (neurofibromatosis). Abdominal pain. painful defecation. prune-belly syndrome). Recent change in diet. respiratory rate. pancreatic calcifications. size. Hard stools. Hyperactive bowel sounds. emotional stress. antihistamines. Rectal: Sphincter tone.Constipation 57 Constipation Chief Complaint: Constipation. fever. Soiling characteristics and time of day. Soiling in the perianal area. Extremities: Joint tenderness. anterior anal displacement. streaks of blood on stools. Past Medical History: Recent illness. Laboratory Evaluation: Electrolytes. housing move. Sphincter reflex: Gentle rubbing of the perianal skin results in reflex contraction of the external anal sphincter.” well. icterus. Family History: Constipation. hepatomegaly. rectal ulcers. bed rest. straining. dermatitis. breast­ feeding. rabbit-like pellets)? Withholding behavior. pheochromocytoma). pulse. occult blood. oropharyngeal candidiasis (AIDS). Stool in a cavernous ampulla. jaundice. dry. consistency. coeliac disease). fatty stools. Dietary History: Excessive cow's milk or limited fiber consumption. perianal ulcers. aluminum­ containing antacids. Abdomen: Distention. oral ulcers (inflammatory bowel. Rectal prolapse. Abdominal X-ray: Air fluid levels. CBC with differential. Vital Signs: BP (hypertension. foul odor. riboflavin deficiency). fever. . Mouth: Cheilosis (cracked lips. peripheral neuropathy (B6. glossitis (B12. fecal masses above the pubic symphysis and in the left lower quadrant. stooling pattern birth to the present. enuresis. Are stools formed or scybalous (small. Social History: Recent birth of a sibling. Eyes: Decreased pupillary response. urinary incontinence. folate deficiency). dilation.

heat. cow's milk. coffee ground material). History of Present Illness: Duration and frequency of hematemesis. hemorrhoids Behavioral issues Mental retardation Neurogenic Disorders Hirschsprung disease Intestinal pseudoobstruction Cerebral palsy Myelomeningocele Spinal cord injury Transverse myelitis Spinal dysraphism Neurofibromatosis Myopathies Rickets Prune-belly syndrome Endocrine and Metabolic Disorders Hypothyroidism Diabetes mellitus Pheochromocytoma Hypokalemia Hypercalcemia Hypocalcemia Diabetes insipidus Renal tubular acidosis Porphyria Amyloidosis Lipid storage disorders Miscellaneous Disorders Anal or rectal stenosis Anteriorly placed anus Appendicitis Celiac disease Scleroderma Lead poisoning Viral hepatitis Salmonellosis Tetanus Chagas disease Drugs Hematemesis and Upper Gastrointestinal Bleed­ ing Chief Complaint: Vomiting blood. hematocrit. anorexia nervosa Voluntary Stool Withholding Megacolon Painful defecation: Anal fissure. low roughage Deficient fluid: Fever. volume of blood. . character­ istics of vomitus (bright red blood. immobility. perianal dermatitis. Forceful retching prior to hematemesis (Mallory-Weiss tear).58 Hematemesis and Upper Gastrointestinal Bleeding Differential Diagnosis of Constipation in Neonates and Young Infants Meconium ileus Meconium plug syndrome Functional ileus of the newborn Small left colon syndrome Volvulus Intestinal web Intestinal stenosis Intestinal atresia Intestinal stricture (necrotizing enterocolitis) Imperforate anus Anal stenosis Anterior ectopic anus Anterior anal displacement Hirschsprung disease Acquired aganglionosis Tumors Myelodysplasia Hypothyroidism Maternal opiates Inadequate nutrition/fluids Excessive cow’s milk consumption Absence of abdominal musculature (prune-belly syndrome) Cerebral palsy Differential Diagnosis of Constipation in Older Infants and Children Physiologic Causes Breast milk.

duodenitis Children (1-12 years) Esophagitis.Hematemesis and Upper Gastrointestinal Bleeding 59 Abdominal pain. Vital Signs: Supine and upright pulse and blood pressure (orthostatic hypotension) (resting tachycardia indicates a 10-20% blood volume loss. eso­ phagitis. creatinine. NSAIDs Infants (30 days­ 1 year) Gastritis. Skin: Delayed capillary refill. Mouth: Oropharyngeal lacerations. dehydration. na­ sopharyngeal bleeding . Extremities: Edema. or malnourished. Chest: Gynecomastia. gastric ulcer. colonoscopy. gastric/esoph­ ageal duplication. stool color. ecchymoses (coagulopathy). Note whether the patient looks “ill. vas­ cular malformation. confusion. hemorrhoids. bleeding scan. esophageal varices. fissures. Hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome). occult blood testing. bowel sounds. postural hypotension indicates a 20-30% blood loss). splenomegaly. Neurologic: Decreased mental status. international normalized ratio (INR). bleeding disorders. Medications: Alcohol. Esophagogastroduodenoscopy. Weight loss. jaundice. increased skin elasticity (Ehlers-Danlos syndrome). jaundice. Laboratory Evaluation: CBC. gait. electro­ lytes. Rectal: Masses. Gastrointestinal surgery. anticoagu­ lants. gastritis. gastric ulcer. BUN. anorexia. Mallory-Weiss tear. bright red foods. AST. platelet count. Meckel's scan. vascular mal­ formations. labial and buccal pigmenta­ tion (Peutz-Jeghers syndrome). ALT. steroids. nasal bleeding. cold extremities. Past Medical History: Diabetes. renal failure. liver disease. aspirin. duodenal ulcer. nose bleeds. Heart: Systolic ejection murmur. GGTP. breath sounds. nonsteroidal anti-inflammatory drugs. masses. temperature. abnormal pigmentation (Peutz-Jeghers syndrome). hematobilia. Polyps. peptic ulcer. prior bleeding episodes. Abdomen: Dilated abdominal veins.” well. electrolytes. pallor. bleeding time. hematochezia. aortoesophageal fistula Leiomyoma. gastritis. reticulocyte count. Type and cross-match for 2-4 units of packed RBC and transfuse as needed. drinks. duodenitis Less Common Coagulopathy. salicylates. diaphoresis. petechiae. Differential Diagnosis of Upper Gastrointestinal Bleeding Age Neonates (0-30 days) Common Swallowed maternal blood. distention. Eyes: Scleral pallor. glucose. glucose. foreign body. partial thromboplastin time (PTT). Physical Examination General Appearance: Pallor. hepatic atrophy. leiomy­ oma Esophageal varices. melena. tenderness.

aspirin. NSAIDs. change in stool caliber. pale extremities. recent hematocrit. intestinal duplica­ tion. or malnourished. Past Medical History: Barium enema. hematemesis. liver atrophy. hernias. Constipation. Mouth: Buccal mucosa discolorations or pigmentation (Henoch-Schönlein purpura or Peutz-Jeghers syndrome). Change in bowel habits. air fluid levels). ulcers. gastritis. pallor. esophageal varices. abdominal pain. polyps. rashes. melena). excessive straining during defecation. fever. Physical Examination General Appearance: Dehydration. streaks on stool. malaise. confusion. Hirschsprung's entero­ colitis. Genitourinary: Testicular atrophy. Medications: Anticoagulants. Laboratory Evaluation: CBC (anemia). pulse. respiratory rate. Gross or occult blood. diarrhea. Mallory-Weiss tear Less Common Thrombocytopenia. Chest: Breath sounds. Vital Signs: BP (orthostatic hypotension). well. Skin: Delayed capillary refill. liver function tests. peptic ulcer. color of bleeding (gross blood. Heart: Systolic ejection murmurs.60 Melena and Lower Gastrointestinal Bleeding Age Adolescents (12 years-adult) Common Duodenal ulcer. Fecal mucus. esopha­ gitis. masses. Spider angiomata. Neurologic: Anxiety. anorexia. midgut volvulus Less Common Vascular malformations. distention. Abdominal x-ray series (thumbprinting. Dieula­ foy's ulcer. weight loss. jaundice. Epistaxis. coagulopathy . colonoscopy. quantity. fissures. Eyes: Pale conjunctiva. Extremities: Cold. icterus. Colitis. Rectal: Hemorrhoids. swal­ lowed maternal blood. vomiting. pallor. splenomegaly. Differential Diagnosis of Lower Gastrointestinal Bleeding Age Neonates (0-30 days) Common Anorectal lesions. milk allergy. Abdomen: Masses. necrotizing enterocolitis. upper GI series. purpura. sigmoidoscopy. anorectal pain. temperature (tachycardia). tenderness. Note whether the patient looks ill. hematobilia Melena and Lower Gastrointestinal Bleeding Chief Complaint: Anal bleeding History of Present Illness: Duration.

acquir­ ed thrombocytopenia Children (1-12 years) Henoch-Schönlein purpura. intussus­ ception (under 3 years). vasculitis (SLE). milk pro­ tein allergy Juvenile polyps. polyps. Pseudomembranous colitis . anal fissure. in­ testinal duplication. adenocarcinoma. anal fissure. Meckel's diverticulitis. inflammatory bowel dis­ ease Adolescents (12 years-adult) Arteriovascular malformation.Melena and Lower Gastrointestinal Bleeding 61 Age Infants (30 days­ 1 year) Common Anorectal lesions. hemolytic-uremic syn­ drome. infectious diarrhea. infec­ tious diarrhea. hemor­ rhoids. nodular lymphoid hyperplasia Inflammatory bowel dis­ ease. midgut volvulus. in­ fectious diarrhea Less Common Vascular malformations. HenochSchönlein purpura. intussusception (under 3 years) Meckel's diverticulitis.

62 Melena and Lower Gastrointestinal Bleeding .

prior pregnancies. breast atrophy. marijuana. clitoromegaly. History of Present Illness: Date of last menstrual period. dieting. Chest: Galactorrhea. Neck: Thyroid enlargement or nodules. impaired breast development. menstrual regularity. cool dry skin (hypothyroidism). hirsutism. temporal balding (hyperandrogenism. free T4.Amenorrhea 63 Gynecologic Disorders Amenorrhea Chief Complaint: Missed period. Vital Signs: Pulse (bradycardia). headaches. Gyn: Pubic hair distribution. Symptoms of pregnancy (nausea. Weight loss or gain. vision changes. excessive exercise. Neurologic: Focal motor deficits. vaginal septum. hypothyroidism). Eyes: Visual field defects. bitemporal hemianopsia (pituitary adenoma). galactorrhea (prolactinoma). TSH. age of breast development. pregnancy testing. psychologic stress. Past Medical History: History of dilation and curettage. Primary amenorrhea (absence of menses by age 16) or secondary amenorrhea (cessation of menses after previously normal menstruation). sexual activity. Note whether the patient looks “ill” or well. chemotherapeutic agents. Heart: Bradycardia (hypothyroidism). Extremities: Tremor (hyperthyroidism). uterine enlargement. Skin: Acne. prolactin. vaginal atrophy. Abdomen: Abdominal striae (Cushing’s syndrome). tricyclic antidepressants. . blood pressure. Laboratory Evaluation: Pregnancy test. ovarian cysts or tumors. temperature (hypothermia. Medications: Contraceptives. possibility of pregnancy. Progesterone challenge test. Lifestyle changes. inguinal or labial masses. postpartum infection (Asherman’s syndrome). digoxin. obesity. Physical Examination General Appearance: Secondary sexual characteristics. body habitus. respirations. deep voice (hyperandrogenism). Age of menarche. breast tenderness). postpartum hemorrhage (Sheehan's syndrome). Hot flushes (hypoestrogenism). drugs (marijuana). imperfo­ rate hymen.

drugs tumor Pituitary-related: Hypopituitarism. Endometrial biopsy. History of Present Illness: Last menstrual period. obesity. Psychologic stress. cervix. Heart: Murmurs. hypothyroidism. obesity. postcoital or intermenstrual bleeding. hormonal contraception. Cervical polyps. menstrual regularity. beta-HCG. adnexal tenderness. uterine size. fine thinning hair (hypothyroidism). galactorrhea. type and screen. infiltration. number of soaked pads per day. endocrine disorders. petechiae. renal. Von Willebrand's disease. coagulopathies. Past Medical History: Obstetrical history. ovarian failure Outflow tract-related Imperforate hymen Transverse vaginal septum Agenesis of the vagina. oral contraceptives. athlet­ ics. age of menarche. eating disorder. molar pregnancy). . Hyperthyroidism. fever. Physical Examination General Appearance: General body habitus. Gyn: Cervical motion tenderness. gonorrhoeae. Family History: Coagulopathies. polycystic ovary syndrome. Chest: Breath sounds. cervicitis. possibility of pregnancy. pelvic inflammatory disease. spontaneous abortion. Hyperprolactinemia. von Willebrand's screen. dental bleeding. Differential Diagnosis of Abnormal Vaginal Bleeding: Chronic anovulation. abdominal pain. NSAIDs. passing of clots. trauma. signs of shock. uterus Uterine synechiae Androgen excess Polycystic ovarian syndrome Adrenal tumor Adrenal hyperplasia Ovarian tumor Other endocrine causes Thyroid disease Cushing syndrome Abnormal Vaginal Bleeding Chief Complaint: Abnormal vaginal bleeding. duration and frequency of menses. pelvic ultrasound. anticoagulants. Thyroid. uterine myoma endometriosis. Changes in hair or skin texture. hirsutism. tumor. platelets. Laboratory Evaluation: CBC. tachycardia. Chlamydia test. weight changes. INR/PTT. orthostatic vitals. cervical lesions. Skin: Pallor. infarction Ovarian-related: Dysgenesis. or hepatic disease. cervix culture for N. endometriosis.64 Abnormal Vaginal Bleeding Differential Diagnosis of Amenorrhea Pregnancy Hormonal contraception Hypothalamic-related: Stress. retained tampon. diabetes mellitus. lightheadedness. exercise. agen­ esis. medroxyprogesterone. adrenal disease. Vital Signs: Assess hemodynamic stability. skin texture. sexual activity. Note whether the patient looks “ill” or well. bleeding time. hypotension. Neck: Thyroid enlargement. Breasts: Masses. pregnancy (ectopic pregnancy.

cul-de-sac fullness. pallor. Mittelschmerz. Physical Examination General Appearance: Moderate or severe distress. Chlamydia. inflammatory bowel disease. Nonreproductive Causes of Pelvic Pain Gastrointestinal: Appendicitis. mesenteric adenitis. pregnancy). Prior pelvic infection. Gynecologic Disorders: Pelvic inflammatory disease. . Fever or vaginal discharge. chlamydia culture. enlarged uterus. threatened abortion. intrauterine pregnancy with corpus luteum bleeding. onset. renal calculus. age of menarche. ovarian cyst hemorrhage or rupture. menstrual interval. UA with micro. adnexal torsion. Past Medical History: Surgical history. Hegar's sign (softening of uterine isthmus. abnormal vaginal bleeding (quantify). local then generalized tenderness. Note whether the patient looks “ill” or well. Medications: Oral contraceptives. missed menstrual period. gonorrhea. duration. duration. Urinary Tract: Urinary tract infection. endometriosis. positive pregnancy test.Pelvic Pain and Ectopic Pregnancy 65 Pelvic Pain and Ectopic Pregnancy Chief Complaint: Pelvis pain. Rh type. Type and hold. endometriosis. pregnancy). intraabdominal bleeding). prior ectopic pregnancy. primary dysmenorrhea. Heart: Murmurs. respiratory rate (tachypnea). GC. Differential Diagnosis of Pelvic Pain Pregnancy-Related Causes: Ectopic pregnancy. Laparoscopy. pelvic tumor. obstetrical history. irritable bowel syndrome. delayed capillary refill. symptoms of pregnancy (breast tenderness. Chest: Breath sounds. transvaginal ultrasound. tumor. characteristics of pelvic pain. Skin: Cold skin. spontaneous abortion. temperature (low fever). bloating). Abdomen: Cullen's sign (periumbilical darkening. sexually transmitted diseases. History of Present Illness: Pelvic or abdominal pain (bilateral or unilateral). Chadwick's sign (cervical cyanosis. adnexal tenderness. cervical motion tenderness. Pelvic: Cervical discharge. incomplete abortion. Laboratory Evaluation: Quantitative beta-HCG. rebound tenderness. shoulder pain. intrauterine device. Date of last menstrual period. Vital Signs: BP (orthostatic hypotension). CBC. pulse (tachycardia).

66 Pelvic Pain and Ectopic Pregnancy .

hearing. bruises. Anxiety or depression Medications: Dosage. temporal tenderness.Headache 67 Neurologic Disorders Headache Chief Complaint: Headache History of Present Illness: Quality of pain (dull. temporal. visual field deficits. sensory disturbances. nasal discharge (sinusitis). rate of onset (gradual or sudden). frontal bossing. weight. neck muscle tenderness. gait. and effect of medications. pulse. Exacerbation by foods (cheese). Aura or Prodrome: Visual scotomata. and painless oral ulcers. Cigarettes. illegal drugs. menses. past illnesses. development delay. Does the headache interfere with normal activity or cause the child to stop playing? Awakening from sleep. temporal bruits (arteriovenous malformation). throbbing). Neck: Rigidity. Parental description of their headaches. head circumference. strength. fever. interaction with parents. Exacerbation by light or sounds. emotional upset. cranial tenderness. growth percentiles. . Family History: Migraine headaches in parents. suboccipital. age of onset. Aggravating or Relieving Factors: Relief by analgesics or sleep. Alopecia. rashes. or changing position. Head injuries. Dilated scalp veins. sad or withdrawn? Vital Signs: BP (hypertension). intellectual skills. Conjunctival injection. Nose: Rhinorrhea (cluster headache). lack of linear growth. frequency of use. effect of supine posture. papilledema. Postural lightheadedness. Associated Symptoms: Numbness. Physical Examination General Appearance: Note whether the patient looks “ill” or well. Review Systems: Changes in personality. respiratory rate. Eyes: Downward deviation of the eyes ("sunset-ring" increased intracranial pressure). Sinuses tenderness (sinusitis) to percussion. Stressful events. memory. exercising. vision. Head: Macrocephaly. time course of typical headache episode. Skin: Pallor. restricted jaw opening (TMJ dysfunction). gingivitis. Progression in severity. time of day. pharyngeal erythema. photophobia. straining. pupil reactivity. motion sickness. Height. lacrimation (cluster headache). allergies. Birth control pills. location (retro-orbital. analgesic use. blurred vision. or balance. vomiting. sharp. nausea. Increasing frequency. Past Medical History: Growth delay. “The worst headache ever” (subarachnoid hemorrhage). vertigo. Café au lait spots in the axillae or inguinal areas (neurofibromatosis). neck stiffness (meningitis). alcohol. Weight loss. bilateral or unilateral). Facial angiofibromas (adenoma sebaceum). diplopia. extraocular movements. Mouth: Tooth tenderness. Social History: School absences. temperature (fever). Emotional problems at home or in school. Masseter muscle spasm. petechiae. weakness. band-like. weakness.

Does he speak during the spell? Does the child remember the spells afterward? What is the child like after the episode (confused. hospitalizations. clonus. Medications: Antidepressants. anger. alert)? Can the child describe what happens? Past Medical History: Illnesses. injuries. post-ictal weakness or paralysis. extraocular muscle dysfunction. noncompliance with anticonvulsant medication. metabolic disorders. CT scans.68 Seizures. Spells and Unusual Movements Extremities: Absent femoral pulses. loss of conscious­ ness. tics. Aura before seizure (irritability. MRI scan. sleep disturbance. antiseizure medications. memory impairment. coordination. incontinence of urine or feces. temporomandibular joint syndrome Postlumbar puncture Posttraumatic headache Chronic Progressive Headache Central nervous system infection Hydrocephalus Pseudotumor cerebri Brain tumor Vascular malformation Subdural hematoma Arnold-Chiari malformation Lead poisoning Seizures. fever. Spells and Unusual Movements Chief Complaint: Seizure History of Present Illness: Time of onset of seizure. deep tendon reflexes. Can the patient tell when an episode will start? Warning signs. cranial nerve function. Babinski sign. duration. sensation. lethargy). triggers for the spells (crying. description of seizure. CBC with differential. previous functioning. streptococcal in­ fection liver disease. migraine. Tourette syndrome. . Rheumatic fever. epilepsy. Disorientation. frequency of episodes. Family History: Similar episodes in family. motor strength. lower blood pressures in the legs (coarctation of the aorta). anxiety. Neurologic Examination: Mental status. boredom. Electroencephalograms. tonic-clonic movements. ataxia. hyperreflexia. INR/PTT. trauma). spasticity. rheumatic fever. stimulants. ESR. Laboratory Evaluation: Electrolytes. behavioral change. tremors. Recurrent and Chronic Headaches: Temporal Patterns Acute Recurrent Headache Migraine Cluster headache Acute sinusitis Hypertension Intermittent hydrocephalus Vascular malformation Subarachnoid hemorrhage Carbon monoxide poisoning Chronic Nonprogressive Headache Tension-type headache Chronic sinusitis Ocular disorder Dental abscess. Past seizures.

neck rigidity. lumbar puncture. extraocular movements. tongue or buccal lacerations. focal weakness (Todd's paralysis). urine toxicology. Differential Diagnosis of Seizures. pallor). Vital Signs: Growth percentiles. chest compressions). Neuro: Dysarthria. papilledema. wheeze (aspiration). trauma. pupil reactivity and equality. pulse. Unilateral port-wine facial nevus (Sturge-Weber syndrome). respiratory rate. body position during the event. Observe the patient performing tasks (tying shoes. BP (hypertension). EEG. neurofibromas (Von Recklinghausen's disease). visual field deficits. temperature (hyperpyrexia). Note whether the patient looks well or ill. Babinski's sign. facial angiofibromas (adenoma sebaceum). state of consciousness before. Spells. murmurs. . sensory deficits. fractures. Stridor. hypopigmented ash leaf spots (tuberous sclerosis). incontinence. wheezing. Chest: Rhonchi. Regurgitation after feedings. Extremities: Cyanosis. Vomitus in oral cavity during the event. Perianal: Incontinence of urine or feces. postictal confusional state. MRI. Skin: Café-au-lait spots. developmental delay. walking). HEENT: Head trauma.Apnea 69 Physical Examination General Appearance: Post-ictal lethargy. Heart: Rhythm. CBC. resuscitative efforts (rescue breaths. History of Present Illness: Length of pause in respiration. hypotonia or hypertonia. Laboratory Evaluation: Glucose. electrolytes. RPR/VDRL. during and after the event. gum hyperplasia (phenytoin). Unusual movements. anticonvulsant levels. cranial nerve palsies. and Unusual Movements Epilepsy Movement disorders Tics Myoclonic syndromes Sleep Benign Hyperexplexia (exaggerated star­ tle response) Myoclonus-opsoclonus Shuddering spells Dystonia Torsion Transient torticollis Sandifer syndrome Drugs Dyskinesias Metabolic/genetic Reflex dystrophy Nocturnal Physiologic Choreoathetosis Benign Familial Paroxysmal Sydenham chorea Huntington chorea Drugs Behavioral/Psychiatric Disorders Pseudoseizures Automatisms Dyscontrol syndrome Attention-deficit hyperactivity disor­ der Benign paroxysmal vertigo Migraine Parasomnias Syncope Breathholding spells Apnea Chief Complaint: Apnea. Change in skin color (cyanosis.

developmental delay. mental retardation. Skin: Cool. Nose: Nasal flaring. head circumference percentiles. elicit drugs. Neurologic: Mental status. BUN. intercostal retractions. crackles. masses. alcohol. Respiratory difficulties after birth. Extremities: Dependent edema. difficulties during labor and delivery. Perinatal History: Prenatal exposure to infectious agents. O2 saturation. sudden infant death syndrome. murmurs. obstruction. gag reflex. prior acute life­ threatening events (ALTEs). scars. Preductal and postductal pulse delay (right arm and leg pulse comparison). periodic breathing. ECG. excessive daytime sleepiness. S2. blood pressure. previous involvement of the family with child protective services. Cranial nerve function. tongue. strength. Family History: Genetic or metabolic disorders. S1. Chest: Increased respiratory effort. CBC. nasal secretions. creatinine. Vital Signs: Length. septal deviation or polyps. weight. electrolytes. barrel chest. consang­ uinity. Physical Examination General Appearance: Septic appearance. Grunting. temperature. digital clubbing. Neck: Masses. respirations. nephromegaly. calcium. nocturnal enuresis. Pulse. Immunizations: Pertussis. Heart: Rate and rhythm. Laboratory Evaluation: Glucose. mottled extremities. delayed capillary refill. Social history: Physical abuse. magnesium. Mouth: Structure of the lips. asthma. palate.70 Apnea Loud snoring. bruises. Abdomen: Hepatomegaly. . stridor. mucosal erythema. enlarged thyroid. level of consciousness. enlarged lymph nodes. neonatal death. Past Medical History: Abnormal growth. muscle tone. prolonged pauses in respiration. tonsillar lesions. Medications accessible to the child in the home. fetal loss. wheezing. Irregular respirations. maternal exposure to opioids.

drugs. murmurs. Chest: Breathing pattern (Cheyne-Stokes hyperventilation). orientation to person. Fever. narcotics. Skin: Cyanosis. primitive reflexes (snout. papilledema. respiratory rate. petechia. hemotympanum (basal skull fracture). skull fracture). Dehydration. place. Confusion.Delirium. agitation. facial weakness. septic appearance. lacerations. Medications: Insulin. mini-mental status exam. wheezes. obtundation (awake but not alert). glossitis (B12 deficiency). Mouth: Tongue or cheek lacerations. headache. injection site fat atrophy (diabetes). Neuro: Strength. Battle's sign (ecchymosis over mastoid process). . masses. gallops. coma (cannot be awakened). raccoon sign (periorbital ecchymosis. Coma and Confusion 71 Differential Diagnosis of Apnea Central Nervous System Dandy-Walker malformation Arnold-Chiari malformation Seizures Hypotonia. jaundice. Heart: Rhythm. pulse. anticholinergics. somnolence. epilepsy (post-ictal state). splinter hemor­ rhages. extraocular movements. time. Past Medical History: Suicide attempts or depression. delayed capillary refill. Babinski's sign. Neck: Neck rigidity. cranial nerves 2-12. Activity and symptoms prior to onset. masses. weakness Ondine's curse Metabolic/Toxic Hypoglycemia Hypocalcemia Hyponatremia Acidosis Hypomagnesemia Opioids Medium-chain acyl-CoA dehydrogenase deficiency Upper Airway Craniofacial syndromes Laryngomalacia Rhinitis Choanal stenosis/atresia Croup Upper Airway (continued) Adenotonsillar hypertrophy Epiglottitis Post-extubation Vocal cord paralysis Anaphylaxis Lower Airway Pneumonia Bronchiolitis Pertussis Cardiovascular Structural disease Dysrhythmia Gastrointestinal Gastroesophageal reflux Miscellaneous Sepsis Meningitis Munchausen syndrome by proxy Delirium. temperature (fever). Head: Skull tenderness. crackles. splenomegaly. stupor (unconscious but awakable with vigorous stimulation). Coma and Confusion Chief Complaint: Confusion. lethargy. History of Present Illness: Level of consciousness. Eyes: Pupil size and reactivity. ptosis. impaired concentration. Abdomen: Hepatomegaly. Note whether the patient looks “ill” or well. atrophic tongue. recent events. Physical Examination General Appearance: Incoherent speech. Vital Signs: BP (hypertensive encephalopathy).

creatinine. Differential Diagnosis of Delirium: Hypoxia. head trauma.72 Delirium. liver function tests. dehydration. BUN. . electrolytes. Coma and Confusion suck. hypoglycemia (insulin overdose). stroke. hyperglycemia. meningitis. CT/MRI. Laboratory Evaluation: Glucose. drug intoxication. glabella. O2 saturation. uremia. systemic infection. ketoacidosis. intracranial hemorrhage. factitious coma. palmomental grasp). electrolyte imbalance. vitamin B12 deficiency. encephalitis. urine toxicology screen. seizure.

Perineal excoriation. early infant deaths. pulse (tachycardia). persistent dribbling of urine. straining to urinate. mannitol. Perineal sensation. constipation. Vital Signs: Blood pressure (hypertension). polyuria. dehydration. daytime and nighttime enuresis. urea. Differential Diagnosis of Polyuria Water Diuresis Primary polydipsia Diabetes insipidus Obstruction by posterior urethral valves. respirations. leg pain. uteropelvic junction obstruction. Social History: History of foreign body insertion or sexual abuse. gait disturbance. Physical Examination General Appearance: Signs of dehydration. hemangiomas. lumbosacral midline defects. palpable bladder. muscle strength in the legs and feet. Feeding schedule. fever. sodium chloride. third heart sound. mineralocorticoid deficiency or excess. nephrolithiasis Renal infarction secondary to sickle-cell disease Chronic pyelonephritis Solute Diuresis: Glucose. infants with poor growth or dehydration. dysuria. Gait disturbances. Vomiting. Abdomen: Masses. sacral hairy patch. septic appearance. Family History: Family members with polydipsia. encopresis Past Medical History: Urinary tract infections. growth pattern. ectopic ureter. growth failure. Parental age of toilet training. renal disease. Constant daytime thirst or waking at night to drink. Lower extremity weakness. Extremities: Asymmetric gluteal cleft. anal reflex (sacral nerve function). Abdominal and perineal pain. alkali ingestion . history of lumbar puncture. Chest: Breath sounds. gluteal wasting. Use of harsh soaps for bathing. gluteal lipoma. Neurologic Examination: Deep tendon reflexes. constipation. Enuresis and Urinary Frequency Chief Complaint: Excessive urination. diabetes. sacral hyperpigmentation. back pain. urgency. Growth percentiles.Polyuria. Enuresis and Urinary Frequency 73 Renal and Endocrinologic Disorders Polyuria. genitourinary disorders. Rectal Examination: Rectal sphincter laxity. temperature. History of Present Illness: Time of onset of excessive urination. spinal cord injury. recurrent urinary tract infections. sacral dimple or sinus tract. Poor urinary stream. overfeeding. Heart: Murmurs. Excessive fluid intake.

phenobarbital. cascara laxatives. hydronephrosis). ibuprofen. Face: Periorbital edema (nephritis. menstruation. acute glomerulonephritis). creatinine. Skin: Pallor. dehydration. Heart: Rhythm. Family History: Hematuria. Throat: Pharyngitis. respiratory rate. recent trauma. Bloody diarrhea (hemolytic-uremic syndrome). Note whether the patient looks “ill” or well. Recent or recurrent upper respiratory illness (adenovirus). pulse. discoid rash (systemic lupus erythematosus). nephromegaly (Wilms' tumor. phenytoin. petechiae (Henoch-Schönlein purpura). Genitourinary: Discharge. aspirin. Strenuous exercise. berries. Frequency. food coloring. myoglobinuria. Henoch-Schönlein purpura). . fever. joint swelling. dysuria. phenytoin. Eyes: Lens dislocation. bleeding disorders. malar rash. joint pain. meatal stenosis. renal disease. Physical Examination General Appearance: Signs of dehydration. sickle cell anemia. urine culture. rifampin. Laboratory Evaluation: Urinalysis with microscopic. Past Medical History: Recent sore throat (group A streptococcus). Vital Signs: Hypertension (acute renal failure. unequal peripheral pulses (aortic coarctation). abdominal or perineal pain. gallops. rhubarb. Extremities: Peripheral edema (nephrotic syndrome). tissue passage in urine. hemophilia.74 Hematuria Differential Diagnosis of Enuresis and Urinary Frequency Infection Uteropelvic junction obstruction Obstructive ectopic ureter Posterior urethral valves Nephrolithiasis Diabetes mellitus Diabetes insipidus Wilms tumor Neuroblastoma Pelvic tumors Fecal impaction Hematuria Chief Complaint: Blood in urine. murmurs. foreign body. duration and timing of hematuria. nephrotic syndrome). Back: Costovertebral angle tenderness (renal calculus. ibuprofen. dot-and-fleck retinopathy (Alport's syndrome). cyclophosphamide. History of Present Illness: Color of urine. Social History: Occupational exposure to toxins. stone passage. Causes of Red Urine: Pyridium. Medications Associated with Hematuria: Warfarin. polycystic kidney disease. suprapubic pain. fever. Abdomen: Masses. flava beans. beets. abdominal bruits. Foley catheterization. umbilical catheterization. pyelonephritis). joint tenderness (rheumatic fever). trauma. Rashes. Chest: Breath sounds. naproxen. suprapubic tenderness. flank pain (renal colic). streptococ­ cal skin infection (glomerulonephritis). hepatitis B or C exposure. arthritis (systemic lupus erythematosus. hemoglobinuria. deafness (Alport's syndrome). Perinatal History: Birth asphyxia. ecchymoses. hypertension.

Past Medical History: Renal disease. hearing deficits. Specific Laboratory Evaluation: Complement levels. Medications: Chemotherapy agents. edema. deafness. INR/PTT. MRI scan. sickle cell screen. antineutrophil cytoplasmic antibodies.Proteinuria 75 BUN. antiglomerular basement membrane antibodies (Goodpasture's syndrome). renal ultrasonography. History of Present Illness: Protein of 1+ (30 mg/dL) on a urine dipstick. short stature. Family History: Renal disease. Protein above 4 mg/m2/hour in a timed 12. renal scan. audiogram (Alport's syndrome).to 24-hour urine collection (significant proteinuria). arthralgias. Advanced Laboratory Evaluation: Voiding cystourethrogram. Differential Diagnosis of Microscopic Hematuria Glomerular Diseases Benign familial or sporadic hematuria (thin membrane nephropathy) Acute postinfectious glomerulonephritis Hemolytic-uremic syndrome IgA nephropathy (Berger's disease) Alport's syndrome (familial nephritis) Focal segmental glomerulonephritis Nonglomerular Diseases Strenuous exercise Dehydration Fever Menstruation Foreign body in urethra or bladder Urinary tract infection: bacterial. hypertension. CBC. anti-streptolysin-O and anti-DNAse B (poststreptococcal glomerulonephritis). urine calcium-to-creatinine ratio. intravenous pyelography. adenovirus. purified protein derivative (PPD). heart disease. tuberculosis Hypercalciuria Urolithiasis Sickle cell trait or disease Trauma Drugs and toxins Masturbation Tumors Wilms' tumor Tuberous sclerosis Renal or bladder cancer Leukemia Coagulopathy Anatomical abnormalities Hydronephrosis Ureteropelvic junction obstruction Cystic kidneys Polycystic kidney disease Medullary cystic disease Vascular malformations Arteriovenous fistula Renal vein thrombosis Nutcracker syndrome Papillary necrosis Parenchymal infarction Munchausen syndrome-by-proxy Membranoproliferative glomerulo­ nephritis Systemic lupus erythematosus Henoch-Schönlein nephritis Polyarteritis Hepatitis-associated glomerulonephritis Proteinuria Chief Complaint: Proteinuria. . Urinalysis of first-degree relatives (Alport's syndrome or benign familial hematuria). CT scan. Prior proteinuria. renal biopsy. antinuclear antibody.

rash. electrolytes. Renal ultrasound. cholesterol. hypopigmented macules. Recumbent and ambulating urinalyses. joint swelling. BUN. complement levels.76 Proteinuria Physical Examination General Appearance: Signs of dehydration. Laboratory Evaluation: Urinalysis for spot protein/creatinine ratio. aminoglycosides and penicillins) Heavy metals Ischemic tubular injury . Extremities: Joint tenderness. Differential Diagnosis of Proteinuria Functional/Transient (<2+ on urine dipstick) Fever Strenuous exercise Cold exposure Congestive heart failure Seizures Emotional stress Isolated Proteinuria Orthostatic proteinuria (60% of cases) Persistent asymptomatic proteinuria Glomerular Disease Minimal change nephrotic syndrome Glomerulonephritis Postinfectious Membranoproliferative Membranous IgA nephropathy Henoch-Schönlein purpura Systemic lupus erythematosus Hereditary nephritis Tubulointerstitial Disease Reflux nephropathy Interstitial nephritis Hypokalemic nephropathy Cystinosis Fanconi's syndrome Tyrosinemia Lowe syndrome Tubular toxins Drugs (eg. total protein. albumin. CBC. creatinine. antinuclear antibody. Skin: Café-au-lait spots. antistreptolysin-O titer (ASO). Vital Signs: Temperature (fever). Ears: Dysmorphic pinnas. Note whether the patient looks “ill” or well. voiding cystourethrogram.

Growth percentiles. spider angiomata. hereditary angioedema. cyanosis. anti­ hypertensives. pharyngitis. liver function tests. crackles. oral contraceptives. pulse (tachycardia). ankle edema. HEENT: Periorbital edema. Poor exercise tolerance. Physical Examination General Appearance: Respiratory distress. hepatomegaly. scleral icterus. triglycerides. . Family History: Lupus erythematosus. Laboratory Evaluation: Electrolytes. temperature. alcohol. Allergies: Allergic reactions to foods (cow's milk). dietary history. pregnancy. respiratory rate (tachypnea). jaundice. diuretics. Poor protein intake (Kwashiorkor). albumin. Skin: Xanthomata. malnutrition. Renal disease. weight gain. shifting dullness. S3 gallop. renal disease. Periorbital edema. Poor feeding. sexual activity. distribution (localized or generalized). Past Medical History: Menstrual cycle. insect bite puncta. Heart: Displacement of point of maximal impulse. illicit drugs. inability to keep up with other children. History of Present Illness: Duration of edema. fussiness.Swelling and Edema 77 Swelling and Edema Chief Complaint: Swollen ankles. Conjunctival injection. restlessness. poor weight gain. pulses. Alport syn­ drome. dullness to percussion. erythema. silent precordium. rash. cystic fibrosis. Social History: Exposure to toxins. fatigue. friction rub. redness. clubbing. decreased urine output. premenstrual bloating. Decreased urine output. pain. bruits. Extremities: Pitting or non-pitting edema (graded 1 to 4+). Medications: Over-the-counter drugs. erythema. allergies. shortness of breath. urine protein. Bloody urine (smoky or red). CBC. Vitals: BP (upright and supine). chest x-ray. Note whether the patient looks “ill” or well. Abdomen: Distention. chemicals. intermittent or persistent swelling. deafness. sinus tenderness. murmur. splenomegaly. Rash. pallor. estrogen. chronic diarrhea (protein losing enteropathy). lithium. Chest: Breath sounds. nasal polyps.

blurred vision. Note whether the patient looks “toxic” or well. dehydration. Duration of polyuria. noncompliance with insulin. dyspnea. decreased visual acuity. Vital Signs: BP (hypotension). fever. trauma. hypothermia). dysuria (urinary tract infection). New onset of diabetes. History of Present Illness: Initial glucose level. Abdomen: Hypoactive bowel sounds (ileus). chills. pulse (tachycardia). intertriginous candidiasis. right lower quadrant tenderness .78 Diabetic Ketoacidosis Differential Diagnosis of Edema Increased Hydrostatic Pressure Congestive heart failure Pericarditis Superior vena cava syndrome Arteriovenous fistula Venous thrombosis Lymphatic obstruction by tumors Syndrome of inappropriate ADH secre­ tion Steroids Excessive Iatrogenic fluid administration Increased Capillary Permeability Rocky Mountain spotted fever Stevens-Johnson syndrome Decreased Oncotic Pressure (Hypoproteinemia) Nephrotic syndrome Liver disease (alpha -antitrypsin defi­ 1 ciency. pancreatitis.) Pancreatic pseudocyst Severe anemia Zinc deficiency Diabetic Ketoacidosis Chief Complaint: Malaise. infectious hepatitis) Cirrhosis Galactosemia Kwashiorkor Marasmus Cystic fibrosis Inflammatory bowel disease Protein-losing enteropathy (cow's milk allergy) Intestinal lymphangiectasia Celiac disease Bezoar Infection (Giardia sp. Heart: Murmurs. abdominal pain (appendicitis). infection. stress. localized fat atrophy (insulin injections). Eyes: Diabetic retinopathy (neovascularization. ear pain (otitis media). noncompli­ ance with insulin. erythrasma. Chest: Rales. Kussmaul respirations (deep sighing breathing). lethargy. infections. polyphagia. dehydration. Cough. Factors that May Precipitate Diabetic Ketoacidosis. dry mucous membranes (dehydration). renal disease. Past Medical History: Age of onset of diabetes. apple odor). temperature (fever. Physical Examination General Appearance: Somnolence. respiratory rate (tachypnea). ketones. anion gap. Skin: Decreased skin turgor. Ears: Tympanic membrane erythema (otitis media). infection. rhonchi (pneumonia). polydipsia. weight loss. pregnancy. delayed capillary refill. myocardial infarction. hospitalization. hemorrhages). Mouth: Acetone breath odor (musty.

Diagnostic Criteria for DKA. bicarbonate. potassium. . CBC. chloride.3. cellulitis. UA (proteinuria. serum ketones. Glucose �250. Neurologic: Confusion. uremia. renal tubular acidosis. costovertebral angle tenderness (pyelonephritis). Non-Anion Gap Acidoses: Diarrhea. Laboratory Evaluation: Glucose. Differential Diagnosis Ketosis-causing Conditions: Alcoholic ketoacidosis or starvation. pH <7. ketone positive >1:2 dilutions. suprapubic tenderness (cystitis). phosphate.Diabetic Ketoacidosis 79 (appendicitis). bicarbonate <15. sodium. Chest x-ray. salicylate or methanol poisoning. anion gap. creatinine. Extremities: Abscesses. ketones). Acidosis-causing Conditions Increased Anion Gap Acidoses: Lactic acidosis. hyporeflexia. BUN.

80 Diabetic Ketoacidosis .

dominant hue and the color pattern. what treatments have been tried. what symptoms were associated with it. shape of the lesions. flat. History of Present Illness: Time of rash onset. color of the lesions. Laboratory Diagnosis: Virus isolation or antigen detection (blood. excoriations. . arrangement of several lesions (annular. lichenification. Vital Signs: Temperature. pulse. dermatitis. warmth. Distribution of skin lesions (face. measles. urticaria. Fever. diabetes. mumps. home situation. what it resembled. Throat: Pharyngeal erythema. buccal mucosa lesions. blood pressure. malaise. eczema. cough. Chest: Rhonchi. scarlet fever. rocky mountain spotted fever. palms. prior history of chicken pox. extremities). masses. trunk. dermatomal). Location where the rash first appeared. Extremities: Rash on hands. Kawasaki’s disease. Heart: Murmurs. alcohol. Physical Examination General Appearance: Respiratory distress. urine). surgery. Ears: Tympanic membranes. cold. Exposure to persons with rash. Lymph Nodes: Cervical. conjunctivitis. feet. axillary. Color or surface changes. drug reactions. soles. Eyes: Conjunctival erythema. induration. nasopharynx. joint pain. joint tenderness. conjunctiva. rubella. Immunizations: Vaccination status. crackles . coryza. asthma. Abdomen: Tenderness. Past Medical History: Prior rashes. Mouth: Soft palate macules. drug eruption. surface characteristics (scaly. Social History: Drugs. vesicles. serpiginous. toxic appearance. Medications: Prescription and nonprescription. eczema. including the nails and mucous membranes. verrucous). papules. Sun exposure. location. ulceration. Exposure to allergens or irritants. hepatosplenomegaly. Skin: Complete skin examination. abdominal pain. hospitalizations. joint swelling.Rash 81 Dermatologic. wheezing. pattern of spread (chest to extremities). respirations. Acute and convalescent antibody titers. macules. Family History: Similar problems among family members. margin character. allergic rhinitis. Hematologic Rheumatologic Disorders Rash and Chief Complaint: Rash. inguinal lymphadenopathy. psychologic stress. Differential Diagnosis: Varicella. texture changes. crusting. rubella. Sore throat. measles. headache. erythema.

Bone tenderness. ecchymotic patterns (eg. hematemesis. aspirin or other nonsteroidals) in the home.82 Bruising and Bleeding Bruising and Bleeding Chief Complaint: Bruising History of Present Illness: Time of onset of bruising. nephromegaly. family stress. recurring infections. Rectal: Stool occult blood. erythema. Bone pain. . Social History: History of child abuse. size. nasal eschar. Physical Examination General Appearance: Ill-appearance. shape. Vital Signs: Tachypnea. epistaxis. bleeding at injection sites. Mouth: Gingivitis. oozing from gums. rhonchi. jaundice. melena. abdominal pain. Family History: Bleeding disorders. doubled-over phone cord). bleeding into joints. joint tenderness. petechiae. Partial albinism (Hermansky-Pudlak syndrome). blood pressure (orthostatic changes). anticoagulant use. belt buckle shape. Nose: Epistaxis. Chest: Wheezing. Lymph Nodes: Cervical or axillary lymphadenopathy Eyes: Conjunctival pallor. Palpable purpura on legs (vasculitis. pallor. symmetrical). Past Testing: X-ray studies. Weight loss. trauma. availability of rodenticides or antiplatelet drugs (eg. anomalies of the radius bone (thrombocytopenia absent radius [TAR] syndrome). splenomegaly. Henoch-Schönlein purpura). Prolonged bleeding after minor surgery (circumcision) or after loss of primary teeth. mucous membrane bleeding. Skin: Appearance and distribution of petechiae (color. Extremities: Muscle hematomas. endoscopy. extensive bleeding with trauma. joint pain. Abdomen: Hepatomegaly. Is the bleeding lifelong or of recent onset? Hematuria. Hyperextensible skin (Ehlers-Danlos syndrome). spontaneous ecchymoses. oral petechiae. tachycardia. bleeding gums. diffuse. cachexia. fever. Heart: Murmurs. hypermobile joints (Ehlers-Danlos syndrome. hemarthroses. Past Medical History: Oozing from the umbilical stump after birth. fever. folliculitis (neutropenia). Child abuse.

erythema. respirations. blood cultures. splenomegaly. Christmas disease) Von Willebrand disease Vitamin K deficiency Hemorrhagic disease of the newborn Trauma Vasculitis Giant cell (temporal) arteritis Takayasu arteritis Polyarteritis nodosa Kawasaki syndrome Henoch-Schönlein purpura Leukocytoclastic ("hypersensitivity”) vasculitis Wegener granulomatosis Churg-Strauss syndrome Essential cryoglobulinemia Systemic lupus erythematosus Juvenile rheumatoid arthritis Mixed connective tissue disease Dermatomyositis. spirochetal infection. Lymph Nodes: Cervical lymphadenopathy. hep­ arin Afibrinogenemia/dysfibrinogenemia Clotting factor deficiencies (hemophilia A. low voltage. Urinalysis: Proteinuria. irritable. Heart: Murmur. increase of leukocytes in urine sediment (sterile pyuria) ECG: Prolonged PR. irritability. CRP. rhinorrhea. abdominal pain. lasting 5 days or more. Chest: Breath sounds. Joint swelling. myocardial . platelet count. Extremities: Edema. vomiting. Skin: Diffuse polymorphous rash (macules. joint tenderness. ST-T changes. Physical Examination General Appearance: Ill appearance. Abdomen: Tenderness. fissures of lips. red. gallop rhythm. temperature (fever). Desquamation of the fingers or toes. conjunctival suffusion. arrhythmias. Eye redness. swollen. electrolytes. usually around nails and spreading over palms and soles (late). erythema of the hands and feet. Diarrhea. Redness. strawberry tongue. CXR: Cardiomegaly Echocardiography: Pericardial effusion. distant heart sounds. dryness or fissuring of lips. History of Present Illness: Fever of unknown cause. quinidine. Eyes: Bilateral conjunctival congestion (dilated blood vessels without purulent discharge). B. scleroderma Bacterial or viral infection. rickettsial infection Malignancy Kawasaki Disease Chief Complaint: Fever. coronary aneurysm. swollen hands and feet.Kawasaki Disease 83 Differential Diagnosis of Bruising and Bleeding Hemolytic uremic syndrome Thrombotic thrombocytopenic purpura Uremia Paraproteinemia Myelodysplastic syndrome Phenytoin. valproic acid. liver function tests. erythematous exanthem) of the trunk. ESR. throat culture. blood pressure (hypotension). chest pain. Absence of cough. bullae. Mouth: Erythema of lips. QT intervals. vomiting. hepatomegaly. abnormal Q wave. uveitis. erythematous tongue. morbilliform or scarlatiniform rash. Laboratory Evaluation: CBC with differential. Diffuse injection of oral and pharyngeal mucosa. arthritis/arthralgias. antistreptolysin-O titer. warm. Vital Signs: Pulse (tachycardia).

drug reaction. viral syndrome. . Differential Diagnosis: Scarlet fever (no hand. toxic shock syndrome. Stevens-Johnson syndrome (mouth sores. foot. crusts). cutaneous bullae. or conjunctival involve­ ment).84 Kawasaki Disease infarction. measles (rash occurs after fever peaks and begins on head/scalp).

arthritis. swallowing difficul­ ties Intrauterine growth delay Physical Examination General Appearance: Cachexia. Observation of parent-child interaction. or malnourished. diarrhea. dehydration. dysentery. feeding difficulties. illness Eating disorders Aberrant parental nutritional beliefs Food faddism Diaphoresis or fatigue while eating Poor suck. Developmental Examination: Delayed abilities for age on developmental screening test.” well. change in appetite. previous hospitalizations. Polyuria. Developmental History: Developmental delay. swallow Vomiting. cough. Date when the parents became concerned about the problem. motor inactivity (congenital encephalopathy or rubella). hyperkinesis Bilious vomiting Recurrent pneumonias. current stress within the family. feeding problems. polydipsia. Parental histories of neglect or abuse in childhood. Siblings with poor growth. infantile posture. blood transfusions). 24-hour diet recall. dietary calendar. warmth. marital discord. fever. perinatal jaundice. steatorrhea Diarrhea. medications or drugs (tobacco. financial difficulties. maternal illness. Deaths in siblings or relatives during early childhood (metabolic or immunologic disorders). fatigue during feeding. anorexia Recurrent infections Rash. Decreased vocalization. jaundice. affection. increased hand and finger activities (thumb sucking). Past Medical History: Excessive crying. loss of developmental milestones. Family History: Short stature. abdominal pain. respiratory rate. weakness Jaundice Polyuria. Vital Signs: Pulse (bradycardia). Proper formula preparation. alcohol). temperature (hypother- . Historical Findings in Failure to Thrive Poor Caloric Intake Breast-feeding mismanagement Lactation failure Improper formula preparation Maternal stress. poor diet. History of Present Illness: Weight loss. Perinatal History: Delayed intrauterine growth. Poor suck and swallow. types and amounts of food offered. polyphagia Irritability. vomiting. intravenous drug abuse. Passive or withdrawn behavior. Note whether the patient looks “ill. fever Inflammatory bowel disease Radiation. parental heights and the ages at which the parents achieved puberty. Nutritional History: Appropriate caloric intake. Parental dietary restrictions (low fat). Social History: Parental HIV-risk behavior (bisexual exposure. Birth weight. Unexplained injuries. polydipsia.Failure to Thrive 85 Behavioral Disorders and Trauma Failure to Thrive Chief Complaint: Inadequate growth. expression­ less facies. BP. constipation Mental retardation. chemotherapy Hypogeusia.

length. congenital malformations. dry conjunctiva. growth percentiles. Chest: Barrel shaped chest. protein. albumin. muscle wasting. liver function tests. thyroid studies. rhonchi. Skin: Pallor. obstructive uropathy). CNS disease Diencephalic syndrome . cleft palate Cardiopulmonary disease Hypotonia. patent ductus arteriosus murmur. Extremities: Edema. illness Eating disorders (older children) Aberrant parental nutritional beliefs Food faddism Improper formula preparation Micrognathia. hepatomegaly (galactosemia). decreased bowel sounds (malabsorption. Mouth: Dental erosions. skin laxity. mas­ culinization Irritability Laboratory Evaluation: CBC. transferrin. Periumbilical adenopathy. poor diet. electrolytes.86 Failure to Thrive mia). Rectal: Occult blood. Eyes: Cataracts (rubella). Lymph Nodes: Cervical or supraclavicular lymphadenopathy. masses. mass Rash. short stature. Weight. weakness Jaundice. cheilosis (cobalamin defi­ ciency). oropharyngeal lesions. Masses (pyloric stenosis or obstructive uropathy). jaundice. icterus. Neuro: Decreased peripheral sensation. ataxia Abdominal distension Fever Clubbing Perianal skin tags Short stature Cachexia. hepatomegaly Ambiguous genitalia. cleft lip and palate Poor suck. Neck: Thyromegaly. tenderness. Physical Examination Findings in Growth Deficiency Micrognathia. glossitis (Pellagra). Genitalia: Hypospadias (obstructive uropathy). aortic stenosis murmur. and head circumference. joint erythema. swallow Hyperkinesis Bulging fontanelle. Abdomen: Protuberant abdomen. Differential Diagnosis of Failure to Thrive Poor Caloric Intake Breast-feeding mismanagement Lactation failure Maternal stress. papilledema Nystagmus. Head: Temporal wasting. Heart: Displaced point of maximal impulse. cleft lip. spleno­ megaly. rash. tenderness.

volvulus. responsiveness). Rate and pattern of acquisition of skills. Parents' description of the child's current skills. Developmental quotient (DQ): Developmental age divided by the child's chronologic age x 100. developmental regressions. Hirschsprung disease Metabolic disorders Poor Caloric Digestion/Assimilation/Absorption Cystic fibrosis Shwachman-Diamond syndrome Fat malabsorption Enteric infections Infection Inflammatory bowel disease Cancer treatment Gluten-sensitive enteropathy Carbohydrate malabsorption Intestinal lymphangiectasia Zinc deficiency Increased Caloric Demands Chronic infection HIV infection Malignancies Autoimmune disorders Chronic renal disease Chronic liver disease Diabetes mellitus Adrenal hyperplasia Hypercalcemia Hypothyroidism Metabolic errors Miscellaneous CNS impairment Prenatal growth failure Short stature Lagging-down Normal thinness Developmental Delay Chief Complaint: Delayed development.Developmental Delay 87 Poor Caloric Retention Increased intracranial pressure Labyrinthine disorders Esophageal obstruction. Developmental History: Age when parents first became concerned about delayed development. gastroesophageal reflux. preampullary obstruction Intestinal obstruction. Vision and hearing deficits. How does he move around? How does he use his hands? How does he let you know what he wants? What does he understand of what you say? What can you tell him to do? What does he like to play with? How does he play with toys? How does he interact with other children? Behavior in early infancy (quality of alertness. .

88 Developmental Delay Perinatal History: In utero exposure to toxins or teratogens, maternal illness or trauma, complications of pregnancy. Quality of fetal movement, poor fetal weight gain (placental dysfunction). Apgar scores, neonatal seizures, poor feeding, poor muscle tone at birth. Growth parameters at birth, head circumference. Past Medical History: Illnesses, poor feeding, vomiting, failure to thrive. Weak sucking and swallowing, excessive drooling. Medications: Anticonvulsants, stimulants. Family History: Illnesses, hearing impairment, mental retardation, mental illness, language problems, learning disabilities, dyslexia, consanguinity. Social History: Home situation, toxin exposure, lead exposure. Physical Examination Observation: Facial expressions, eye contact, social, interaction with caretak­ ers and examiner. Chronically ill, wasted, malnourished appearance, lethargic/fatigued. Vital Signs: Respirations, pulse, blood pressure, temperature. Height, weight, head circumference, growth percentiles. Skin: Café au lait spots, hypopigmented macules (neurofibromatosis), hemangiomas, telangiectasias, axillary freckling. Cyanosis, jaundice, pallor, skin turgor. Head: Frontal bossing, low anterior hairline; head size, shape, circumference, microcephaly, macrocephaly, asymmetry, cephalohematoma; short palpebral fissure, flattened mid-face (fetal alcohol syndrome), chin shape (prominent or small). Eyes: Size, shape, and distance between the eyes (small palpebral fissures, hypotelorism, hypertelorism, upslanting or downslanting palpebral fissures). Retinopathy, cataracts, corneal clouding, visual acuity. Lens dislocation, corneal clouding, strabismus. Ears: Size and placement of the pinnae (low-set, posteriorly rotated, cupped, small, prominent). Tympanic membranes, hearing. Nose: Broad nasal bridge, short nose, anteverted nares. Mouth: Hypoplastic philtrum. Lip thinness, downturned corners, fissures, cleft, teeth (caries, discoloration), mucus membrane color and moisture. Lymph Nodes: Location, size, tenderness, mobility, consistency. Neck: Position, mobility, swelling, thyroid nodules. Lungs: Breathing rate, depth, chest expansion, crackles. Heart: Location and intensity of apical impulse, murmurs. Abdomen: Contour, bowel sounds, tenderness, tympany; hepatomegaly, splenomegaly, masses. Genitalia: Ambiguous genitalia (hypogonadism). Extremities: Posture, gait, stance, asymmetry of movement. Edema, clinodactyly, syndactyly, nail deformities, palmar or plantar simian crease. Neurological Examination: Behavior, level of consciousness, intelligence, emotional status. Equilibrium reactions (slowly tilting and observing for compensatory movement). Protective reactions (displacing to the side and observing for arm extension by 7 to 8 months). Motor System: Gait, muscle tone, muscle strength (graded 0 to 5), deep tenon reflexes. Primitive Reflexes: Palmar grasp, Moro, asymmetric tonic neck reflexes. Signs of Cerebral Palsy: Fisting with adducted thumbs, hyperextension and scissoring of the lower extremities, trunk arching. Poor suck-swallow, excessive drooling.

Developmental Delay 89 Diagnostic Studies: Karyotype for fragile X syndrome, fluorescent in situ hybridization (FISH), DNA probes. Magnetic resonance imaging (MRI) or CT scan. Metabolic Studies: Ammonia level, liver function tests, electrolytes, total CO2, venous blood gas level. Screen for amino acid and organic acid disorders. Organic acid assay, amino acid assay, mucopolysaccharides assay, enzyme deficiency assay. Other Studies: Audiometry, free-thyroxine (T4), thyroid-stimulating hormone (TSH), blood lead levels, electrotromyography, nerve conduction velocities, muscle biopsy. Differential Diagnosis of Developmental Delay
Static global delay/mental retardation Idiopathic mental retardation Chromosomal abnormalities or genetic syndromes Hypoxic-ischemic encephalopathy Structural brain malformation Prenatal exposure to toxins or teratogens Congenital infection Progressive global delay Inborn errors of metabolism Neurodegenerative disorders Rett syndrome AIDS encephalopathy Congenital hypothyroidism Language disorders Hearing impairment Language processing, expressive language disorders Pervasive developmental disorder or autistic disorder Gross motor delay Cerebral palsy Peripheral neuromuscular disorders Syndromes Associated With Development Delay Down Syndrome Fragile X Syndrome Prader-Willi Syndrome Turner Syndrome Williams Syndrome Noonan syndrome Sotos Syndrome Klinefelter Syndrome Angelman Syndrome Cornelia de Lange Syndrome Beckwith-Wiedemann Syndrome

Psychiatric History
I. Identifying Information: Age, gender.
II. Chief Complaint: Reason for the referral.
A. History of the Present Illness (HPI) (1) Developmental Level: Cognitive, affective, interpersonal develop­ ment. (2) Neurodevelopmental Delay: Cerebral palsy, mental retardation,

90 Psychiatric History congenital neurologic disorders. (3) Organic Dysfunction: Problems with perception, coordination, attention, learning, emotions, impulse control. (4) Thought Disorders: Delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms (eg, affective flattening, paucity of thought or speech). (5) Anxiety and Behavioral Symptoms: Phobias, obsessive-compul­ sive behaviors, depression. (6) Temperamental Difficulty: Adaptability, acceptability, demandingness. (7) Psychophysiological Disorders: Psychosomatic illnesses, conversion disorder. (8) Unfavorable Environment: Family or school problems. (9) Causative Factors a. Genetic Disorders: Dyslexia, attention-deficit hyperactivity disorder, mental retardation, autism. b. Organic Disorders: Malnutrition, intrauterine drug exposure, prematurity, head injury, central nervous system infec­ tions/tumors, metabolic conditions, toxins. c. Developmental Delay: Immaturity and attachment problems. Relationships with parents and siblings; developmental mile­ stones, peer relationships, school performance d. Inadequate Parenting: Deprivation, separation, abuse, psychiatric disorders. e. Stress Factors: Illness, injury, surgery, hospitalizations, school failure, poverty. f. Biological Function: Appetite, sleep, bladder and bowel control, growth delay. g. Relationships: Family and peer problems. h. Significant Life Events: Separation and losses. i. Previous Evaluations: Previous psychiatric and neurological problems and assessments. j. Parental Psychiatric State: Status of each parent and their marriage. Relatives with psychiatric disorders, suicide, alcohol or substance abuse. III. Mental Status Examination A. Physical Appearance (1) Stature: Age-appropriate appearance, precocity, head circumfer­ ence. (2) Dysmorphic Features: Down syndrome, fragile X, fetal alcohol syndrome. (3) Neurological Signs: Weakness, cranial nerve palsies. (4) Bruising: Child abuse. (5) Nutritional State: Obesity, malnutrition, eating disorder. (6) Movements: Tics, biting of lips, hair pulling (ie, Tourette's disorder, anxiety). (7) Spells: Momentary lapses of attention, staring, head nodding, eye blinking (ie, epilepsy, hallucinations). (8) Dress, Cleanliness, Hygiene: Level of care and grooming. (9) Mannerisms: Thumb sucking, nail biting B. Separation: Excessive difficulty in separation. C. Orientation

J. humiliating event). Laterality: Right and left discrimination by age 5. physical. projection.Attempted Suicide and Drug Overdose 91 (1) To person: Verbal children should know their names. (3) To time: A sense of time is formed by age 8 or 9. deprivation. suicidal ideation. M. respiratory . Affect: Anxiety. obsessions. Medications: Antidepressants. spontaneous play. apathy. E. presence of potentially dangerous objects (belts. suicide. depression. mental retardation. hyperactivity. Judgment and Insight: The child’s opinion of the cause of the problem. homicidal ideation. Reasons that the patient has to wish to go on living. sources of emotional stress. rhomboid at age 7. Central Nervous System Function: Soft signs (persistent neurodevelopmental immaturities): (1) Gross Motor Coordination Deficiency: Impaired gait. motive for attempt. Social History: Personal or family history of emotional. I. Reading or Writing Difficulties: Dyslexia. square at age 5. delirium. dysgraphia. Quantity of pills. Availability of other dangerous medications or weapons. family support. hopelessness. Rapid Alternating Movements: Hopping on one foot by age 7. ability to identify body parts by age 5. psychiatric disease. Fantasies and Inferred Conflicts: Dreams. Family History: Depression. Memory: Children can count five digits forward and two backwards. delusions. Adaptive Capacities: Problem-solving ability. Speech and Language Difficulties: Autism. resiliency. temperature. b. cross at age 3 to 4. Intelligence: Vocabulary. regression. Defense Organization: Denial. c. hallucinations. (2) Fine Motor Coordination: Copies a circle at age 2 to 3. Attempted Suicide and Drug Overdose History of Present Illness: Time suicide was attempted and method. divorce. H. (2) To place: Young children should know whether they are away or at home. or sexual abuse. anger. pulse (bradycardia). further desire to commit suicide. Physical Examination General Appearance: Level of consciousness. Young children can tell whether it is day or night. guilt. drawing. Is there a definite plan? Was the action impulsive or planned? Feelings of sadness. Precipitating factor for suicide attempt (death. Did the patient believe that he would succeed in suicide? Is the patient upset that he is still alive? Past Psychiatric History: Previous suicide attempts or threats. where was substance obtained. introversion. extroversion. Vital Signs: BP (hypotension). Thinking Process: Logical and coherent thoughts. Attention Span: Distractibility. D. a. mathematical ability. drawing ability. G. shoe laces). alcohol or drug abuse. K. level of comprehension. L. F. How upset is the child about the problem? N. naming three wishes. phobias. Alcohol intake. marital conflict. helplessness.

Methemoglobin test of blood. depressants). Skin: Dry mucosa (anticholinergic). track marks. aspirin. beta-blockers. mental status. cyanide odor. urine toxicology screen. stimulation. Heart: Arrhythmias. fractures. Liver function tests. Mouth: Breath: Alcohol. Past Medical History: Previous poisonings. late aspirin). Chest: Breath sounds. sedation. chest X-ray. mydriasis. insulin. Physical Examination Vital Signs: Tachycardia (stimulants. respiratory depression. reflexes. calcium channel blocker). heavy metals (lead). Toxicologic Syndromes Toxin Iron Clinical Findings Diarrhea. or central nervous system disease. acetaminophen levels. enteric-coated pills. toxicology screen of urine and serum. iron. lethargy. Ferric chloride urine test for aspirin. rhonchi (aspiration). mydriasis. coma. BUN. Abdomen: Decreased bowel sounds. hypokalemia (lithium). leuko­ cytosis. cholinergic. seizures. Pepto Bismol. chloral hydrate. nystagmus. hyperglycemia Coma. time of ingestion. heart. Cardiac: Bradycardia (beta-blocker. fever (anticholinergics. nystagmus (phenytoin or phencyclidine). Laboratory Evaluation: Glucose (low in alcohols. quantity ingested (number of pills/volume of liquid). Chest: Abnormal respiratory patterns. Alcohol. Was this a suicide attempt or gesture? Vomiting. Eyes: Meiosis. tenderness. Kidney. murmurs. clonus. very moist skin (cholinergic or sympathomimetic). hematemesis. ecchymoses. hyperactive reflexes. Neurologic: Mental status exam. WBC. Neurological: Gait. abdominal pain. Toxicological Emergencies History of Present Illness: Substance ingested. kidney. Laboratory Evaluation: Electrolytes. phenothiazines. bloody stools. glucose. Abdomen: Decreased bowel sounds (anticholinergic or narcotic). tremor. hydrocarbon. HEENT: Signs of trauma. hypoventilation (narcotics. Extremities: Wounds. anticholinergics). oral hypoglycemics. ECG: Prolonged QTc or widened QRS (tricyclic antidepressants). altered consciousness. ecchymoses. Arterial blood gases. decreased bowel sounds Opioids . Ureter and Bladder (KUB) X-ray: Radiopaque pill fragments are seen with calcium. stimulants). high in iron. gastrointesti­ nal. lung. miosis. creatinine. pupil size and reactivity. aspirin. bradycardia. metabolic acidosis.92 Toxicological Emergencies rate.

hypo. disconjugate eye movements Dry mucous membranes and skin. tachycardia. mental status change. blood pressure. D. altered mental status. fever. tachycardia. tactile hallucinations. B. broncho­ rrhea. respiratory alkalosis Muscle twitching. salivation. hypokalemia. myoglobinuria. Past medical history. level of con­ sciousness. nystagmus. response to verbal stimuli. inadequate air exchange). dysrhythmias. ileus. pupillary dilation. track marks. pulse pressure. bradycardia Hyperventilation. Determine the mechanism of injury and details of the trauma. unresponsive. tremor. anxiety. vomiting. agitation.or hyperglycemia. C. flush­ ing Anticholinergics Trauma History: Allergies. urination. tremor. hypotension. widened QRS Nausea. psychosis. convul­ sions. . Last meal. fever. hematemesis. diaphoresis. Medications. defecation. diaphoresis. metabolic acidosis. am­ phetamines. ECG abnormalities Pupillary dilation. pupillary dilation. metabolic acidosis. Circulation: Heart rate. seizures. rigidity. increased creatinine phosphokinase Dry mucosa. vasodilation.Trauma 93 Organophosphates Miosis. cramps. Breathing: Observe chest excursion. agitation. tinnitus. hypertension. phenylpropan­ olamine) Sedative/hypnotics Respiratory depression. blank stare. hypertension Salicylates Phencyclidine (PCP) Tricyclic anti­ depressants Theophylline Adrenergic storm (cocaine. I. Normal speech indicates a patent airway. arrhythmias. urinary and fecal retention. hyperthermia. Auscultate chest. hypothermia. and Events leading up to the injury (AMPLE). arrhythmias. tachycardia. lacrimation. response to painful stimuli. capillary refill. coma. Disability (1) Level of Consciousness: Alert. active bowel sounds. Airway: Check for signs of obstruction (noisy breathing. seizures. Primary Survey: ABCDEs A. altered mental status.

foreign body. cerebrospinal fluid otorrhea. femoral pulse. jaw tenderness/deformity. sensory deficits. Genitourinary: Meatal blood. Rectal: Sphincter tone. bruit. pupil reactivity. bony tenderness. J. Babinski sign. pupil reactivity. hematoma. spine or rib tenderness. capillary refill. nosebleed. pulses. septal hematoma. deformity. G. gum laceration. tenderness. loose or missing teeth. hemotympanum. Secondary Survey A. Mouth: Lip laceration. tenderness. E. globe laceration. tracheal deviation. Standard trauma series (1) Cervical spine (2) Chest X ray (3) Pelvic radiograph (4) Computed Tomography (CT) . CSF rhinorrhea. laceration. hematuria. Eyes: Visual acuity. stridor. deformity/asymmetry. hyphema. Head: Raccoon eyes. Exposure: Completely undress the patient. B. K. Nose: Laceration. deformity. skull fracture. E. bowel sounds. laceration. flail segments. subcutaneous emphysema. pelvis symmetry. Face: Laceration. H. enophthalmos. ecchymosis. C. Ears: Laceration. F. III. venous distention. D. rib and clavicle tenderness or deformity. range of motion. II. N. hematoma. exothalmos. Extremities: Color. deformity. tenderness. hematoma. Radiographic Evaluation of the Blunt Trauma Patient A. laceration. distention. I. heart sounds. scars. cervical spine tenderness/deformity.94 Trauma (2) Neurological Deficit: Four extremity gross motor function. laceration. subcutaneous emphysema. Battle's sign. reflexes. sensation. temperature. lens dislocation. tongue laceration. laceration. occult blood. carotid pulsation. M. tracheal deviation. Neurological Examination: Level of consciousness. Neck: Laceration. Abdomen: Laceration. hematoma. bony tenderness. Back: Ecchymosis. extraocular movements. L. Chest: Symmetry. prostate position. bilateral breath sounds.

38 Ectopic Pregnancy 65 Edema 77 Electrolytes 7 Endocarditis 38 Enuresis 73 EOMI 6 Epiglottitis 30 Epistaxis 60 Failure to Thrive 85 Fever 23 Frequency 73 Gastrointestinal bleeding lower 60 upper 58 Gum hyperplasia 69 Headache 67 Heart Failure 14 Hegar's sign 65 Hematemesis 58 Hematochezia 41. 25 Polyuria 73 .Index Abdominal pain 41 Acute abdomen 41 Acute Diarrhea 54 Adenoma sebaceum 67 Amenorrhea 63 Apnea 69 Asthma 17 Bleeding 82 Bronchiolitis 31 Brudzinski's sign 32 Bruising 82 CBC 7 Cellulitis 37 Cerebral Spinal Fluid 33 Chest pain 13 Chief Compliant 5 Chronic Diarrhea 54 Coma 71 Confusion 71 Congestive Heart Failure 14 Constipation 57 Cough 24-26 Croup 31 Cystitis 33 Delirium 71 Developmental Delay 87 Developmental milestones 10 Developmental quotient 87 Diabetic ketoacidosis 78 Diabetic retinopathy 78 Diarrhea 54 Discharge Note 8 Discharge summary 9 Drug Overdose 91 Dyspnea 14 Ear pain 27 Ecthyma gangrenosum 24. 42 Obtundation 71 Obturator sign 41 Opioids 93 Organophosphates 93 Oropharyngeal Obstruction 18 Orthostatic hypotension 59 Osteomyelitis 39 Otitis Media 27 Parapharyngeal abscess 30 Past Medical History 5 PCP 93 Pediatric history 5 Pelvic Pain 65 Peritonsillar abscess 30 PERRLA 6 Phencyclidine 93 Physical Examination 6 Pneumonia 24. 42 Hematuria 74 Hepatitis 48 Hepatosplenomegaly 52 History 5 History of Present Illness 5 Hoarseness 20 Hypertension 15 Hypertensive retinopathy 15 Iliopsoas sign 41 Infectious diseases 23 Iron 93 Jaundice 48 Kawasaki's Disease 83 Kernig's sign 32 Laryngotracheobronchitis 31 Lower Gastrointestinal Bleeding 60 Lymphadenitis 34 Lymphadenopathy 34 McBurney's point 41. 33 Nephrology 73 Nephromegaly 74 Neurology 67 Newborn examination 7 Obstipation 41. 60 Meningitis 32. 42. 43 Melena 41.

Port-wine nevus 69 Postural hypotension 59 Prescription Writing 9 Procedure Note 10 Progress Notes 8 Proteinuria 75 Psychiatric History 90 Pulmonology 17 Pulsus paradoxicus 17 Pyelonephritis 33 Rash 81 Recurrent Abdominal Pain 42 Renal bruit 15 Retropharyngeal abscess 30 Rovsing's sign 41. 43 RRR 6 Salicylates 93 Seizures 68 Septic Arthritis 39 Spells 68 Stridor 18 Stupor 71 Sturge-Weber syndrome 69 Suicide 91 Swelling 77 Tactile fremitus 26 Todd's paralysis 69 Toxicological Emergencies 92 Toxidromes 93 Trauma 94 Tuberculosis 27 Tuberculous 33 UA 7 Unusual Movements 68 Upper Gastrointestinal Bleeding 58 Urinary Frequency 73 Urinary tract infection 33 Urine analysis 7 Uterine bleeding 64 Vaginal Bleeding 64 Vomiting 44 Von Recklinghausen's disease 69 Wheezing 17 Wilson's disease 49 .