Dr C Naveen Kumar

Paediatrics
9866046878
naveen.cheri@gmail.com
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Dyspnea and Congestive Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . 14

Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Pulmonary Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Wheezing and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Stridor and Oropharyngeal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . 18

Hoarseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Cough and Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Peritonsillar, Retropharyngeal or Parapharyngeal Abscess . . . . . . . . . . 30

Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Croup (Viral Laryngotracheobronchitis) . . . . . . . . . . . . . . . . . . . . . . . . . 31

Bronchiolitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Urinary Tract Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Lymphadenopathy and Lymphadenitis . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Cellulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Acute Abdominal Pain and the Acute Abdomen . . . . . . . . . . . . . . . . . . 41

Recurrent Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Persistent Vomiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Jaundice and Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Hepatosplenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Acute Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Chronic Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

 Hematemesis and Upper Gastrointestinal Bleeding . . . . . . . . . . . . . . . 58

Melena and Lower Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . . . . 60

Gynecologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Amenorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Abnormal Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Pelvic Pain and Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Neurologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Seizures, Spells and Unusual Movements . . . . . . . . . . . . . . . . . . . . . . . 68

Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Delirium, Coma and Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Renal and Endocrinologic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Polyuria, Enuresis and Urinary Frequency . . . . . . . . . . . . . . . . . . . . . . . 73

Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Proteinuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Swelling and Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Diabetic Ketoacidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Dermatologic, Hematologic and Rheumatologic Disorders . . . . . . . . . . 81

Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Bruising and Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Kawasaki Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Behavioral Disorders and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Failure to Thrive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Developmental Delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Psychiatric History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Attempted Suicide and Drug Overdose . . . . . . . . . . . . . . . . . . . . . . . . . 91

Toxicological Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Commonly Used Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

 History and Physical Examination 5

Medical Documentation

Pediatric History
Identifying Data: Patient's name, age, sex; significant medical conditions,
informant (parent).
Chief Compliant (CC): Reason that the child is seeking medical care and
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when and how it began, character of the symptoms; aggravating or
alleviating factors; pertinent positives and negatives, past diagnostic testing.
Past Medical History (PMH): Medical problems, hospitalizations, operations;
asthma, diabetes.
Perinatal History: Gestational age at birth, obstetrical complications, type of
delivery, birth weight, Apgar scores, complications (eg, infection, jaundice),
length of hospital stay.
Medications: Names and dosages.

Nutrition: Type of diet, amount taken each feed, change in feeding habits.

Developmental History: Age at attainment of important milestones (walking,

talking, self-care). Relationships with siblings, peers, adults. School grade and
performance, behavioral problems.
Immunizations: Up-to-date?
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder;
diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, smoking.
Social History: Family situation, alcohol, smoking, drugs, sexual activity.
Parental level of education. Safety: Child car seats, smoke detectors, bicycle
helmets.
Review of Systems (ROS)
General: Overall health, weight loss, behavioral changes, fever, fatigue.
Skin: Rashes, moles, bruising, lumps/bumps, nail/hair changes.
Eyes: Visual problems, eye pain.
Ear, nose, throat: Frequency of colds, pharyngitis, otitis media.
Lungs: Cough, shortness of breath, wheezing.
Cardiovascular: Chest pain, murmurs, syncope.
Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdomi
nal pain, constipation, blood in stools.
Genitourinary: Dysuria, hematuria, polyuria, vaginal discharge, STDs.
Musculoskeletal: Weakness, joint pain, gait abnormalities, scoliosis.
Neurological: Headache, seizures.
Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses
duration, amount of flow.
6 History and Physical Examination

Pediatric Physical Examination

Observation: Child's facial expression (pain), response to social overtures.
Interaction with caretakers and examiner. Body position (leaning forward in
sitting position; epiglottitis, pericarditis). Weak cry (serious illness), high
pitched cry (increased intracranial pressure, metabolic disorder); moaning
(serious illness, meningitis), grunting (respiratory distress).
Does the child appear to be:
(1) Well, acutely ill/toxic, chronically ill, wasted, or malnourished?
(2) Alert and active or lethargic/fatigued?
(3) Well hydrated or dehydrated?
(4) Unusual body odors?
Vital Signs: Respiratory rate, blood pressure, pulse, temperature.
Measurements: Height, weight; head circumference in children 2 years; plot
on growth charts and determine growth percentiles.
Skin: Cyanosis, jaundice, pallor, rashes, skin turgor, edema, hemangiomas,
caf au lait spots, nevi, Mongolian spots, hair distribution, capillary refill (in
seconds).
Lymph Nodes: Location, size, tenderness, mobility and consistency of cervical,
axillary, supraclavicular, and inguinal nodes.
Head: Size, shape, asymmetry, cephalohematoma, bossing, molding, bruits,
fontanelles (size, tension), dilated veins, facial asymmetry.
Eyes: Pupils equal round and reactive to light and accommodation (PERRLA);
extraocular movements intact (EOMI); Brushfield's spots; epicanthic folds,
discharge, conjunctiva; red reflex, corneal opacities, cataracts, fundi;
strabismus (eye deviation), visual acuity.
Ears: Pinnas (position, size), tympanic membranes (landmarks, mobility,
erythema, dull, shiny, bulging), hearing.
Nose: Shape, discharge, bleeding, mucosa, patency.
Mouth: Lips (thinness, downturning, fissures, cleft lip), teeth, mucus membrane
color and moisture (enanthem, Epstein's pearls), tongue, cleft palate.
Throat: Tonsils (erythema, exudate), postnasal drip, hoarseness, stridor.
Neck: Torticollis, lymphadenopathy, thyroid nodules, position of trachea.
Thorax: Shape, symmetry, intercostal or substemal retractions.
Breasts: Turner stage, size, shape, symmetry, masses, nipple discharge,
gynecomastia.
Lungs: Breathing rate, depth, expansion, prolongation of expiration, fremitus,
dullness to percussion, breath sounds, crackles, wheezing, rhonchi.
Heart: Location of apical impulse. Regular rate and rhythm (RRR), first and
second heart sounds (S1, S2); gallops (S3, S4), murmurs (location, position
in cycle, intensity grade 1-6, pitch, effect of change of position, transmission).
Comparison of brachial and femoral pulses.
Abdomen: Contour, visible peristalsis, respiratory movements, dilated veins,
umbilicus, bowel sounds, bruits, hernia. Rebound tenderness, tympany;
hepatomegaly, splenomegaly, masses.
Genitalia:
Male Genitalia: Circumcision, hypospadias, phimosis, size of testes,
cryptorchidism, hydrocele, hernia, inguinal masses.
Female Genitalia: Imperforate hymen, discharge, labial adhesions, clitoral
hypertrophy, pubertal changes.
Rectum and Anus: Erythema, excoriation, fissures, prolapse, imperforate anus.
Anal tone, masses, tenderness, anal reflex.
 Physical Examination of the Newborn 7

Extremities: Bow legs (infancy), knock knees (age 2 to 3 years). Edema (grade
1-4+), cyanosis, clubbing. Joint range of motion, swelling, redness, tender
ness. A "click" felt on rotation of hips indicates developmental hip dislocation
(Barlow maneuver). Extra digits, simian lines, pitting of nails, flat feet.
Spine and Back: Scoliosis, rigidity, pilonidal dimple, pilonidal cyst, sacral hair
tufts; tenderness over spine or costovertebral tenderness.
Neurological Examination:
Behavior: Level of consciousness, intelligence, emotional status.
Motor system: Gait, muscle tone, strength (graded 0 to 5).
Reflexes
Deep Tendon Reflexes: Biceps, brachioradialis, triceps, patellar, and
Achilles reflexes (graded 1-4).
Superficial Reflexes: Abdominal, cremasteric, plantar reflexes
Neonatal Reflexes: Babinski, Landau, Moro, rooting, suck, grasp, tonic
neck reflexes.
Developmental Assessment: Delayed abilities for age on developmental
screening test.
Laboratory Evaluation: Electrolytes (sodium, potassium, bicarbonate, chloride,
BUN, creatinine), CBC (hemoglobin, hematocrit, WBC count, platelets,
differential); X-rays, urinalysis (UA).
Assessment: Assign a number to each problem, and discuss each problem
separately. Discuss the differential diagnosis, and give reasons that support
the working diagnosis. Give reasons for excluding other diagnoses.
Plan: Describe therapeutic plan for each numbered problem, including testing,
laboratory studies, medications, antibiotics, and consultations.

Physical Examination of the Newborn

General Appearance: Overall visual and auditory appraisal of the completely
undressed infant. Weak cry (serious illness), high-pitched cry (increased
intracranial pressure, metabolic disorders), grunting (respiratory distress).
Unusual body odors.
Vital Signs: Respiratory rate (normal 40-60 breaths/min), heart rate (120-160
beats/minute), temperature.
Head: Lacerations, caput, cephalohematoma, skull molding. Fontanelles (size,
tension), head circumference.
Neck: Flexibility and asymmetry.
Eyes: Scleral hemorrhages, cataracts, red reflex, pupil size.
Mouth: Palpate for cleft lip and cleft palate.
Respiratory: Acrocyanosis, retractions, nasal flaring, grunting. Palpation of
clavicles for fractures.
Heart: Position of point of maximal impulse, rhythm, murmurs. Distant heart
sounds (pneumothorax). Comparison of brachial and femoral pulses.
Abdomen: Asymmetry, masses, fullness, umbilicus, hernias. Liver span (may
extend 2.5 cm below the right costal margin), spleen span, nephromegaly.
Male Genitalia: Hypospadias, phimosis, hernia, presence of both testes. Anal
patency
Female Genitalia: Interlabial masses, mucoid vaginal discharge or blood
streaked discharge (normal). Anal patency
Skin: Pink, cyanotic, pale. Jaundice (abnormal in the first day of life), milia
(yellow papules), Mongolian spots (bluish patches).
8 Progress Notes

Extremities: Extra digits, simian lines, pilonidal dimple or cyst, sacral hair tuft,
hip dislocation; a "click" felt on rotation of hips (Barlow maneuver, develop
mental hip dislocation).
Neurologic Examination: Tone, activity, symmetry of extremity movement,
symmetry of facial movements, alertness, consolability, Moro reflex, suck
reflex, root reflex, grasp reflex, plantar reflex.

Progress Notes
Daily progress notes should summarize developments in the patient's hospital
course, problems that remain active, plans to treat those problems, and
arrangements for discharge. Progress notes should address every problem
on the problem list.

Example Progress Note

Date/time:
Subjective: Any problems and symptoms should be charted. Appetite,
pain or fussiness may be included.
Objective:
General appearance.
Vitals, temperature, maximum temperature over past 24 hours, pulse,
respiratory rate, blood pressure. Feedings, fluid I/O (inputs and out
puts), daily weights.
Physical exam, including chest and abdomen, with particular attention
to active problems. Emphasize changes from previous physical
exams.
Laboratory Evaluation: New test results. Circle abnormal values.
Current medications: List medications and dosages.
Assessment and Plan: This section should be organized by problem.
A separate assessment and plan should be written for each problem.

Discharge Note
The discharge note should be written prior to discharge.

Discharge Note

Date/time:
Diagnoses:
Treatment: Briefly describe therapy provided during hospitalization,
including antibiotics, surgery, and cardiovascular drugs.
Studies Performed: Electrocardiograms, CT scan.
Discharge medications:
Follow-up Arrangements:
 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, Diagnostic Tests, Invasive Procedures:

History, Physical Examination and Laboratory Data: Describe the course of

the patient's disease up until the time that the patient came to the hospital,
including pertinent physical exam and laboratory data.
Hospital Course: Describe the course of the patient's illness while in the
hospital, including evaluation, treatment, medications, and outcome of
treatment.
Discharged Condition: Describe improvement or deterioration in the patient's
condition, and describe the present status of the patient.
Disposition: Note the situation to which the patient will be discharged (home),
and indicate who will take care of the patient.
Discharge Medications: List medications and instructions for patient on taking
the medications.
Discharge Instructions and Follow-up Care: Date of return for follow-up care
at clinic; diet.
Problem List: List all active and past problems.
Copies: Send copies to attending, clinic, consultants.

Prescription Writing
Patients name:
Date:
Drug name and preparation (eg, tablets size): Lasix 40 mg
Quantity to dispense: #40
Frequency of administration: Sig: 1 po qAM
Refills: None
Signature
10 Procedure Note

Procedure Note
A procedure note should be written in the chart after a procedure is performed.
Procedure notes are brief operative notes.

Procedure Note

Date and time:

Procedure:
Indications:
Patient Consent: Document that the indications, risks and alternatives to
the procedure were explained to the parents and patient. Note that the
parents and patient were given the opportunity to ask questions and
that the parents consented to the procedure in writing.
Lab tests: Relevant labs, such as the CBC and electrolytes.
Anesthesia: Local with 2% lidocaine.
Description of Procedure: Briefly describe the procedure, including
sterile prep, anesthesia method, patient position, devices used, ana
tomic location of procedure, and outcome.
Complications and Estimated Blood Loss (EBL):
Disposition: Describe how the patient tolerated the procedure.
Specimens: Describe any specimens obtained and lab tests that were
ordered.

Developmental Milestones

Age Milestones

1 month Raises head slightly when prone; alerts to sound; regards

face, moves extremities equally.

2-3 Smiles, holds head up, coos, reaches for familiar objects,
months recognizes parent.

4-5 Rolls front to back and back to front; sits well when
months propped; laughs, orients to voice; enjoys looking around;
grasps rattle, bears some weight on legs.

6 months Sits unsupported; passes cube hand to hand; babbles;

uses raking grasp; feeds self crackers.

8-9 Crawls, cruises; pulls to stand; pincer grasp; plays pat-a

months cake; feeds self with bottle; sits without support; explores
environment.

12 Walking, talking a few words; understands no; says

months mama/dada discriminantly; throws objects; imitates
actions, marks with crayon, drinks from a cup.
 Developmental Milestones 11

Age Milestones

15-18 Comes when called; scribbles; walks backward; uses 4-20

months words; builds tower of 2 blocks.

24-30 Removes shoes; follows 2 step command; jumps with

months both feet; holds pencil, knows first and last name; knows
pronouns. Parallel play; points to body parts, runs, spoon
feeds self, copies parents.

3 years Dresses and undresses; walks up and down steps; draws

a circle; knows more than 250 words; takes turns; shares.
Group play.

4 years Hops, skips, catches ball; memorizes songs; plays

cooperatively; knows colors; uses plurals.

5 years Jumps over objects; prints first name; knows address and
mother's name; follows game rules; draws three part man;
hops on one foot.
12 Developmental Milestones
 Chest Pain 13

Cardiovascular Disorders

Chest Pain
Chief Complaint: Chest pain.
History of Present Illness: Duration of chest pain, location, character
(squeezing, sharp, dull). Progression of pain, frequency, aggravating and
relieving factors (inspiration, exertion, eating). Weight loss, fever, cough,
dyspnea, vomiting, heartburn, abdominal pain. School function and atten
dance. Relationship of pain to activity (at rest, during sleep, during exercise).
Does the pain interfere with the patient's daily activities? Have favorite sports
or other activities continued?
Cardiac Testing: Results of prior evaluations, ECGs, echocardiograms.
Past Medical History: Exercise tolerance, diabetes, asthma, trauma.
Medications: Aspirin.
Family History: Heart disease, myocardial infarction, angina.
Social History: Significant life events, stresses, recent losses or separations.
Elicit drugs, smoking.

Historical Findings for Chest Pain

Acute pain? Abdominal pain, limb pain, head

First time? aches?
Systemic symptoms? Light-headedness, tetany, cramps,
Duration of complaints? dizziness?
Exertional? Dermatomal distribution?
Syncope? Palpitations? Aggravated by rising from supine
Cough? position?
Localized? Poor school attendance?
Reproducible? How? Stressful life events?
Associated symptoms?

Physical Examination
General: Visible pain, apprehension, distress. Note whether the patient looks
ill or well. Positions that accentuate or relieve the pain.
Vital Signs: Pulse (tachycardia), BP, respirations (tachypnea), temperature.
Growth chart and percentiles.
Skin: Cold extremities, pallor.
Chest: Chest wall tenderness. Swelling, trauma, dermatomal lesions, breast
development, gynecomastia, xiphoid process tenderness. Crackles, rhonchi,
wheeze.
Heart: First and second heart sounds; third heart sound (S3), S4 gallop (more
audible in the left lateral position), murmur.
Abdomen: Bowel sounds, tenderness, masses, hepatomegaly, splenomegaly.
Back: Vertebral column deformities, tenderness.
Extremities: Unequal or diminished pulses (aortic coarctation).
Laboratory Evaluation: Electrolyte, CBC, chest X-ray.
14 Dyspnea and Congestive Heart Failure

Differential Diagnosis of Chest Pain

Musculoskeletal Disorders Cardiovascular Disease

Costochondritis Pericarditis
Chest wall syndrome Left ventricular outflow
Tietze syndrome obstruction, aortic murmur
Xiphoid cartilage syndrome Dysrhythmias
Stitch Pulmonary Disorders: Pneumonia,
Precordial catch syndrome pneumothorax, asthma
Slipping rib syndrome Gastrointestinal Disorders:
Idiopathic Disorders: Psychogenic, Esophagitis, gastroesophageal reflux,
hyperventilation peptic ulcer disease
Breast Disorders: Gynecomastia, Vertebral/Radicular Disorders
fibrocystic changes Spinal stenosis
Herniated disk
Vertebral fracture

Dyspnea and Congestive Heart Failure

Chief Complaint: Shortness of breath.
History of Present Illness: Rate of onset of dyspnea (gradual, sudden),
dyspnea on exertion, chest pain. Past episodes, aggravating or relieving
factors, cough, fever, drug allergies. Difficulty keeping up with peers during
play. Feeding difficulty, tachypnea or diaphoresis with feedings, diminished
volume of feeding, prolonged feeding time. Poor weight gain.
Past Medical History: Hypertension, asthma, diabetes.
Medications: Bronchodilators, digoxin, furosemide.
Past Treatment or Testing: Cardiac testing, x-rays, ECGs.

Physical Examination
General Appearance: Respiratory distress, dyspnea, pallor. Note whether the
patient looks ill or well.
Vital Signs: BP (supine and upright), pulse (tachycardia), temperature,
respiratory rate (tachypnea), growth percentiles, growth deficiency.
HEENT: Jugular venous distention.
Chest: Intercostal retractions, dullness to percussion, stridor, wheezing,
crackles, rhonchi.
Heart: Lateral displacement of point of maximal impulse, hyperdynamic
precordium; irregular, rhythm; S3 gallop, S4, murmur.
Abdomen: Hepatomegaly, liver tenderness, splenomegaly.
Extremities: Cool extremities, edema, pulses, cyanosis, clubbing.
Laboratory Evaluation: O2 saturation, chest x-ray (cardiomegaly, effusions,
pulmonary edema).
Differential Diagnosis: Heart failure, foreign body aspiration, pneumonia,
asthma, pneumothorax, hyperventilation.
 Hypertension 15

Hypertension
Chief Complaint: High blood pressure.
History of Present Illness: Current blood pressure, age of onset of hyperten
sion. Headaches, vomiting (increased intracranial pressure), dysuria,
nocturia, enuresis, abdominal pain (renal disease). Growth delay, weight loss,
fevers, diaphoresis, flushing, palpitations (pheochromocytoma).
Perinatal History: Neonatal course, umbilical artery/vein catheterization (renal
artery stenosis).
Past Medical History: Lead exposure; increased appetite, hyperactivity,
tremors, heat intolerance (hyperthyroidism).
Medications Associated with Hypertension: Oral contraceptives,
corticosteroids, cocaine, amphetamines, nonsteroidal antiinflammatory drugs.
Family History: Hypertension, preeclampsia, renal disease,
pheochromocytoma.
Social History: Tobacco, alcohol.

Physical Examination
General Appearance: Confusion, agitation (hypertensive encephalopathy).
Vital Signs: Tachycardia (hyperthyroidism), fever (connective tissue disorder).
BP in all extremities, pulse, asymmetric, respiratory rate.
Skin: Pallor (renal disease), caf au lait spots, hypopigmented lesions (Von
Recklinghausen's disease, tuberous sclerosis), lymphedema (Turner's
syndrome), rashes (connective tissue disease), striae, hirsutism (Cushing's
syndrome), plethora (pheochromocytoma).
HEENT: Papilledema, thyromegaly (hyperthyroidism), moon faces (Cushing's
syndrome); webbing of the neck (Turner's syndrome, aortic coarctation).
Chest: Crackles (pulmonary edema), wheeze, intercostal bruits (aortic
coarctation); buffalo hump (Cushing's syndrome).
Heart: Delayed radial to femoral pulses (aortic coarctation). Laterally displaced
apical impulse (ventricular hypertrophy), murmur.
Abdomen: Bruit below costal margin (renal artery stenosis); Masses
(pheochromocytoma, neuroblastoma, Wilms' tumor). pulsating aortic mass
(aortic aneurysm), enlarged kidney (polycystic kidney disease,
hydronephrosis); costovertebral angle tenderness; truncal obesity (Cushing's
syndrome).
Extremities: Edema (renal disease), joint swelling, joint tenderness (connective
tissue disease). Tremor (hyperthyroidism, pheochromocytoma), femoral
bruits.
Neurologic: Rapid return phase of deep tendon reflexes (hyperthyroidism).
Laboratory Evaluation: Potassium, BUN, creatinine, glucose, uric acid, CBC.
UA with microscopic analysis (RBC casts, hematuria, proteinuria). 24 hour
urine for metanephrine; plasma catecholamines (pheochromocytoma), lipid
profile. Echocardiogram, ECG, renal ultrasound.
Chest X-ray: Cardiomegaly, indentation of aorta (coarctation), rib notching.
16 Hypertension

Differential Diagnosis of Hypertension

Renal

Chronic pyelonephritis Segmental hypoplasia

Chronic glomerulonephritis Ureteral obstruction
Hydronephrosis Renal tumors
Congenital dysplastic kidney Renal trauma
Multicystic kidney Systemic lupus erythematosus
Solitary renal cyst (other connective tissue dis
Vesicoureteral reflux nephropathy eases)

Vascular

Coarctation of the aorta Neurofibromatosis

Renal artery lesions Renal vein thrombosis
Umbilical artery catheterization with Vasculitis
thrombus formation

Endocrine

Hyperthyroidism Pheochromocytoma
Hyperparathyroidism Neuroblastoma, ganglioneuro
Congenital adrenal hyperplasia blastoma, ganglioneuroma
Cushing syndrome Diabetic nephropathy
Hyperaldosteronism Liddle's syndrome

Central Nervous System

Intracranial mass Brain injury

Hemorrhage Quadriplegia

Essential Hypertension

Low renin High renin

Normal renin
 Wheezing and Asthma 17

Pulmonary Disorders

Wheezing and Asthma

Chief Complaint: Wheezing.
History of Present Illness: Onset, duration and progression of wheezing;
current and baseline peak flow rate; severity of attack compared to previous
episodes; fever, frequency of hospitalizations; home nebulizer use; cough.
Aggravating factors: Exercise, cold air, viral or respiratory infections, exposure
to dust mites, animal dander. Seasons that provoke symptoms; foreign body
aspiration.
Past Medical History: Previous episodes, pneumonia, recurrent croup, allergic
rhinitis, food allergies. Baseline arterial blood gas results; pulmonary function
testing.
Perinatal History: Prematurity (bronchopulmonary dysplasia),
Family History: Asthma, allergies, hay fever, atopic dermatitis.

Physical Examination
General Appearance: Respiratory distress, anxiety, pallor. Note whether the
patient looks well, ill, or somnolent.
Vital Signs: Peak expiratory flow rate (PEFR). Temperature, respiratory rate
(tachypnea), depth of respirations, pulse (tachycardia), BP (widened pulse
pressure), pulsus paradoxus (>15 mmHg is significant pulmonary compro
mise).
Skin: Flexural eczema, urticaria.

Nose: Nasal flaring, chronic rhinitis, nasal polyps.

Mouth: Pharyngeal erythema, perioral cyanosis, grunting.

Chest: Sternocleidomastoid muscle contractions, intracostal retractions,

supraclavicular retractions, barrel chest. Expiratory wheeze, rhonchi,

decreased breath sounds, prolonged expiratory phase.
Heart: Distant heart sounds, third heart sound (S3); increased intensity of
pulmonic component of second heart sound (pulmonary hypertension).
Abdomen: Retractions, paradoxical abdominal wall motion (abdomen rises on
inspiration), tenderness.
Extremities: Cyanosis, clubbing, edema.
Laboratory Evaluation: CBC, electrolytes. Pulmonary function tests, urinalysis.
ABG: Respiratory alkalosis, hypoxia.
Chest X-ray: Hyperinflation, flattening of diaphragms; small, elongated heart.
18 Stridor and Oropharyngeal Obstruction

Differential Diagnosis of Wheezing

Infant Older Child

Vascular ring Asthma

Tracheoesophageal fistula Aspiration (reflux, foreign body)
Gastroesophageal reflux Epiglottitis
Asthma Laryngotracheobronchitis (croup)
Viral infection (bronchiolitis, upper Cystic fibrosis
respiratory tract infection) Hypersensitivity pneumonitis
Pertussis Tuberculosis
Cystic fibrosis Tumor
Bronchopulmonary dysplasia Alpha1-antitrypsin deficiency
Congenital heart disease Vocal cord dysfunction

Stridor and Oropharyngeal Obstruction

Chief Complaint: Difficulty breathing.
History of Present Illness: Time of onset of stridor, respiratory distress. Fever,
sore throat, headache, malaise. Voice changes (muffled voice), drooling.
Hoarseness, exposure to infections. Trauma or previous surgery.
Increased stridor with stress; worsening in the supine position; improvement
with the neck extended (congenital laryngomalacia). Cough, cyanosis,
regurgitation, choking with feedings, drooling, foreign body. History of
intubation (subglottic stenosis), hemangiomas.
Perinatal History: Abnormal position in utero, forceps delivery, shoulder
dystocia. Respiratory distress or stridor at birth.

Historical Evaluation of Stridor and Oropharyngeal Obstruction

Oropharyngeal Obstruction Stridor

Fever, sore throat, headache Gradual onset

Muffled voice Acute onset, fever
Craniofacial anomalies Worsens in supine position
Cutaneous abnormalities Perinatal trauma
Neurologic symptoms Method of delivery
Present at birth
Feeding difficulties
Previous intubation

Physical Examination
General Appearance: Adequacy of oxygenation and ventilation, airway stability.
Anxiety, restlessness, fatigue, obtundation. Grunting respirations, muffled
voice, hoarseness, stridor.
Vital Signs: Respiratory rate, tachypnea, shallow breathing. Pulse oximetry.
Tachycardia, fever. Growth percentiles.
Head: Congenital anomalies.
 Stridor and Oropharyngeal Obstruction 19

Skin: Perioral cyanosis, nail cyanosis, clubbing.

Nose: Nasal flaring.

Mouth: Bifid uvula, cleft palate. Symmetrical palate movement. Brisk gag reflex,

tonsil symmetry. Tongue symmetry, movement in all directions, masses.

Neck: Masses, external fistulas, mid-line trachea.
Heart: Murmurs, abnormal pulses, asymmetric blood pressures.
Chest: Wall movement and symmetry, retractions, chest diameter, accessory
muscle use (severe obstruction), hyperresonance, wheezes.
Abdomen: Retractions, paradoxical abdominal wall motion (abdomen rises on
inspiration), tenderness.
Extremities: Cyanosis, clubbing, edema.

Physical Examination Findings in Stridor and Oropharyngeal

Obstruction

Anxiety, fatigue, lethargy Increased anteroposterior chest diameter

Cyanosis Accessory muscle use
Tachypnea Mouth-breathing
Hyperpnea Grunting, nasal flaring
Shallow breaths Muffled voice
Pulse oximeter <95 % Hyponasal speech
Poor growth Hypernasal speech
Clubbing Low-pitched, fluttering sound
Heart murmur Aphonia
Congenital head and neck Quiet, moist stridor
anomalies Stridor
Bifid uvula Asymmetric wheezes
Enlarged tonsil(s) Neck extended
Neck mass Opisthotonic posture
Asymmetric chest expansion Torticollis
Retractions

Differential Diagnosis of Oropharyngeal Obstruction

Micrognathia Retropharyngeal abscess

Pierre Robin syndrome Parapharyngeal abscess
Treacher Collins syndrome Hemangioma
Macroglossia Lymphangioma
Down syndrome Ranula
Beckwith-Wiedemann syndrome Lymphoma
Lymphangioma Lymphosarcoma
Hemangioma Rhabdomyosarcoma
Lingual thyroid Fibrosarcoma
Tonsillitis/hypertrophy: Bacterial, Epidermoid carcinoma
viral Adenoidal hypertrophy
Uvulitis Palatal hypotonia
Peritonsillar abscess Obesity
20 Hoarseness

Differential Diagnosis of Stridor

Neonatal Older Child

Laryngomalacia Oropharyngeal infection (peritonsillar

Subglottic stenosis abscess, retropharyngeal abscess,
Webs tonsillitis)
Laryngeal cysts Viral infections (croup)
Tracheal stenosis Epiglottitis
Tracheomalacia Bacterial tracheitis
Tracheal cartilage ring defect Aspirated/swallowed foreign body
Laryngeal/tracheal ring calcification Tumor (hemangioma, lymphangioma)
Vascular ring
Pulmonary sling
Innominate artery tracheal compres
sion
Vocal cord paralysis (Arnold-Chiari
malformation, Dandy-Walker cyst,
recurrent laryngeal nerve injury)
Tumor
Trauma (intubation, thermal injury,
corrosive, gastric secretions)

Hoarseness
Chief Complaint: Hoarseness.
History of Present Illness: Age and time of onset, duration of symptoms, rate
of onset, respiratory distress. Fever, hemangiomas, sore throat; prolonged
loud crying or screaming (vocal chord polyps or nodules). Trauma or previous
surgery; exposure to infections, exacerbating or relieving factors.
Perinatal History: Abnormal position in utero, shoulder dystocia,
hyperextended neck during delivery (excessive neck traction).Respiratory
distress or stridor at birth.
Past Medical History: Intubation (subglottic stenosis); prior episodes of croup,
upper respiratory tract infections. Neurologic disorders (hydrocephalus,
Arnold-Chiari malformation), trauma, previous surgery.

Physical Examination
General Appearance: Hoarseness, abnormal sounds/posture, muffled voice;
hyponasal speech, hypernasal speech, quiet, moist stridor, inspiratory stridor,
biphasic stridor; tachypnea.
Vital Signs: Respiratory rate (tachypnea), tachycardia, temperature. Delayed
growth parameters.
Mouth: Tongue symmetry, movement in all directions, masses. Cleft lip, cleft
palate, bifid uvula, enlarged tonsil(s). Mouth-breathing, grunting, nasal flaring;
Neck: Congenital anomalies; neck mass, masses or external fistulas, mid-line
trachea.
Cardiac: Murmurs, asymmetric blood pressures.
Chest: Asymmetric chest expansion, retractions, increased anteroposterior
chest diameter; accessory muscle use, abnormal vocal fremitus, wheezes,
asymmetric wheezes; upright posture, neck extended, opisthotonic posture,
torticollis.
Extremities: Cyanosis, clubbing.
 Hoarseness 21

Differential Diagnosis of Hoarseness

Neonatal Older Child

Laryngomalacia Postnasal drip

Webs Epiglottitis
Subglottic stenosis Recurrent voice abuse (cord
Cystic lesions polyps, nodules)
Excessive secretions (fistulas, Sicca syndromes
gastroesophageal reflux) Neoplasia (papilloma, heman
Vascular tumors (hemangioma, gioma)
lymphangioma) Trauma (postsurgical, intubation)
Cri du chat syndrome Gaucher disease,
Vocal cord paralysis mucopolysaccharidosis
Vocal cord trauma Williams syndrome, Cornelia de
Hypothyroidism, hypocalcemia, Lange syndrome
Farber disease Conversion reaction
Viral infection (laryngitis, croup)
22 Hoarseness
 Fever 23

Infectious Diseases

Fever
Chief Complaint: Fever.
History of Present Illness: Degree of fever; time of onset, pattern of fever;
cough, sputum, sore throat, headache, abdominal pain, ear pain, neck
stiffness, dysuria; vomiting, rash, night sweats. Diarrhea, bone or joint pain,
vaginal discharge.
Past Medical History: Ill contacts. Exposure to mononucleosis; exposure to
tuberculosis or hepatitis; tuberculin skin testing; travel history, animal
exposure; recent dental procedure.
Medications: Antibiotics, anticonvulsants.

Allergies: Drug allergies.

Family History: Familial Mediterranean fever, streptococcal disease, connec

tive tissue disease.

Social History: Alcohol use, smoking.
Review of Systems: Breaks in the skin (insect bites or stings), weight loss,
growth curve failure. Previous surgery or dental work. Heart murmur, AIDS
risk factors.

Historical Findings in Fever of Unknown Origin

Skin breaks? Puncture or laceration.

Insect bites? Tick exposure, flies or mosquitoes.
Unusual or poorly prepared foods? Raw fish, unpasteurized milk.
Onset, periodicity, temperature curve, weight loss, school absence?
Localized pain?
Fever pattern?
Exposures or travel?
Pets? Kitten exposure, exposure to other animals.
Drugs? Any medication.

Review of systems? Rashes, joint complaints, cough, bowel movements.

Blood, urine, stool, and throat cultures?
Complete blood count? Inflammatory disorders usually lead to a rise in
leukocyte count. Falling counts suggest a marrow process.
Screening laboratory procedures? Rise in sedimentation rate.
Tuberculin skin test with controls?

Physical Examination
General Appearance: Lethargy, toxic appearance. Note whether the patient
looks ill or well.
Vital Signs: Temperature (fever curve), respiratory rate (tachypnea), pulse
(tachycardia). Hypotension (sepsis), hypertension (neuroblastoma,
pheochromocytoma). Growth and weight percentiles.
Skin: Rashes, nodules, skin breaks, bruises, pallor. Icterus, splinter hem
orrhages; delayed capillary refill, petechia (septic emboli, meningococcemia),
24 Fever

ecthyma gangrenosum (purpuric plaque of Pseudomonas). Pustules,

cellulitis, furuncles, abscesses.
Lymph Nodes: Cervical, supraclavicular, axillary, inguinal adenopathy.
Eyes: Conjunctival erythema, retinal hemorrhages, papilledema.
Ears: Tympanic membrane inflammation, decreased mobility.
Mouth: Periodontitis, sinus tenderness; pharyngeal erythema, exudate.
Neck: Lymphadenopathy, neck rigidity.
Breast: Tenderness, masses, discharge.
Chest: Dullness to percussion, rhonchi, crackles.
Heart: Murmurs (rheumatic fever, endocarditis, myocarditis).
Abdomen: Masses, liver tenderness, hepatomegaly, splenomegaly; right lower
quadrant tenderness (appendicitis). Costovertebral angle tenderness,
suprapubic tenderness (urinary tract infection).
Extremities: Wounds; IV catheter tenderness (phlebitis) joint or bone tender
ness (septic arthritis). Osler's nodes, Janeway's lesions (endocarditis).
Clubbing, vertebral tenderness.
Rectal: Perianal skin tags, fissures, anal ulcers (Crohn disease), rectal
flocculence, fissures, masses, occult blood.
Pelvic/Genitourinary: Cervical discharge, cervical motion tenderness, adnexal
tenderness, adnexal masses, genital herpes lesions.

Laboratory Evaluation of Fever

Complete blood count, including Serum lactate

leukocyte differential and platelet Cultures with antibiotic sensitivities
count Blood
Electrolytes Urine
Arterial blood gases Wound
Blood urea nitrogen and creatinine Sputum, drains
Urinalysis Chest x-ray
INR, partial thromboplastin time, Computed tomography, magnetic reso
fibrinogen nance imaging, abdominal X-ray

Differential Diagnosis of Fever

Infectious Disease (50% of diagnoses)

Localized Infection
Respiratory tract
Upperrhinitis, pharyngitis, sinusitis
Lower--pneumonia, bronchitis, bronchiectasis, foreign body
Urinary tract infection
Osteomyelitis
Meningitis, encephalitis
Abdominal abscess, appendicitis
Generalized Infection
Common--Epstein-Barr virus, enteric infection (Salmonella, Yersinia species), cat
scratch disease, tuberculosis, hepatitis, cytomegalovirus
Unusual--tularemia, brucellosis, leptospirosis, Q fever, Lyme disease, syphilis,
toxoplasmosis
 Cough and Pneumonia 25

Collagen/Connective Tissue Disorders

Juvenile rheumatoid arthritis
Kawasaki syndrome
Systemic lupus
Rheumatic fever
Other: Vasculitis syndromes, Behet's disease, mixed connective tissue disease

Neoplasia
Lymphoreticular malignancies
Sarcomas
Inflammatory Bowel Disease
Crohn disease

Periodic Fever
Recurrent viral infections
Cyclic neutropenia, familial Mediterranean fever (serositis, arthritis), pharyngitis with
aphthous stomatitis (Marshall syndrome), Borrelia infection, familial dysautonomia
Pseudo-fever of Unknown Origin: Prolonged low-grade fevers without findings on
examination, multiple vague complaints, normal laboratory tests

Cough and Pneumonia

Chief Complaint: Cough
History of Present Illness: Duration of cough, fever. Sputum color, quantity,
consistency. Sore throat, rhinorrhea, headache, ear pain; vomiting, chest
pain, hemoptysis. Travel history, exposure to tuberculosis, tuberculin testing.
Timing of the cough, frequency of cough; cough characteristics. Dry, "brassy"
cough (tracheal or large airway origins). Cough that is most notable when
attention is drawn to it (psychogenic cough). Exposure to other persons with
cough.
Past Medical History: Previous hospitalizations, prior radiographs. Diabetes,
asthma, immunodeficiencies, chronic pulmonary disease.
Medications: Antibiotics
Immunizations: H influenzae, streptococcal immunization.
Allergies: Drug Allergies
Perinatal History: Respiratory distress syndrome, bronchopulmonary dysplasia,
congenital pneumonias.
Psychosocial History: Daycare or school attendance, school absences,
stressors within the family, tobacco smoke.
Family History: Atopy, asthma, cystic fibrosis, tuberculosis, recurrent infections.
Review of Systems: General state of health; growth and development; feeding
history, conjunctivitis, choking, abnormal stools, neuromuscular weakness.

Physical Examination
General Appearance: Respiratory distress, cyanosis, dehydration. Note
whether the patient looks ill well.
Vital Signs: Temperature (fever), respiratory rate (tachypnea), pulse (tachycar
dia), BP, height and weight percentiles.
Skin: Eczema, urticaria.
Lymph Nodes: Cervical, axillary, inguinal lymphadenopathy
Ears: Tympanic membrane erythema.
Nose: Nasal polyps.
26 Cough and Pneumonia

Throat: Pharyngeal cobblestone follicles, pharyngeal erythema, masses,

tonsillar enlargement.
Neck: Rigidity, masses, thyroid masses.
Chest: Chest wall deformities, asymmetry, unequal expansion. Increased vocal
fremitus, dullness to percussion, wheezing, rhonchi, crackles; bronchial
breath sounds with decreased intensity.
Heart: Tachypnea, gallops, murmurs (rheumatic fever, endocarditis,
myocarditis).
Abdomen: Hepatomegaly, splenomegaly.
Extremities: Cyanosis, clubbing.
Neurologic: Decreased mental status, gag reflex, muscle tone and strength,
swallowing coordination.
Laboratory Evaluation: CBC, electrolytes, BUN, creatinine; O2 saturation, UA.
WBC (>15,000 cells/dL), blood cultures. Sputum or deep tracheal aspirate for
Gram's stain and culture. Tuberculin skin test (PPD), cultures and fluorescent
antibody techniques for respiratory viruses.
Chest X-ray: Segmental consolidation, air bronchograms, atelectasis, pleural
effusion.

Differential Diagnosis of Cough by Age

Infant Toddler/Young School- Older School-

Age Age/Adolescent

Infections Viral infections Asthma

Viral/bacterial infections Sinusitis Recurrent viral infections
Tuberculosis Tuberculosis Sinusitis
Gastroesophageal re Gastroesophageal reflux Tuberculosis
flux Inhaled foreign body Mycoplasma
Anomalies Desquamative interstitial Gastroesophageal reflux
Vascular ring pneumonitis Psychogenic cough
Innominate artery com Lymphocytic interstitial Cystic fibrosis
pression pneumonitis Bronchiectasis
Tracheoesophageal Asthma Immunodeficiency
fistula Cough-variant asthma
Pulmonary sequestra Pollutants (cigarette
tion smoke)
Subglottic stenosis Suppurative lung disease
Interstitial pneumonia Cystic fibrosis
Desquamative intersti Bronchiectasis
tial pneumonitis Right middle lobe syn
Lymphocytic interstitial drome
pneumonitis Ciliary dyskinesia syn
Asthma dromes
Cystic fibrosis
Ciliary dyskinesia syn
dromes
Immunodeficiency
 Tuberculosis 27

Tuberculosis
Chief Complaint: Cough and fever.
History of Present Illness: Tuberculin skin test (PPD) results; duration of
cough, sputum, fever, headache. Stiff neck, bone pain, joint pain. Prior
treatment for tuberculosis. Exposure to tuberculosis. Chest roentgenogram
results. Sputum color, quantity, consistency, hemoptysis. Urban, low-income
population, homeless.
Travel History: Travel to South America, Southeast Asia, India.
Past Medical History: Previous pneumonia, previous hospitalizations, prior
radiographs, AIDS risk factors. Diabetes, asthma, steroids,
immunodeficiencies, chronic pulmonary disease.
Medications: Antihistamines.

Allergies: Drug allergies.

Family History: Source case drug resistance. Tuberculosis, recurrent

infections, chronic lung disease.

Review of Systems: General state of health; growth and development; feeding
history, abnormal stools, neuromuscular weakness.
Social History: Daycare or school attendance.

Physical Examination
General Appearance: Respiratory distress. Note whether the patient looks ill
or well.
Vital Signs: Temperature (fever), respiratory rate (tachypnea), pulse (tachycar
dia), BP, growth percentiles.
Skin: Rashes, cyanosis, urticaria.
Lymph Nodes: Lymphadenopathy (cervical, supraclavicular, axillary, inguinal).
HEENT: Tympanic membrane erythema, neck stiffness.
Chest: Increased vocal fremitus. Increased percussion resonance, rhonchi,
crackles, bronchial breath sounds with decreased intensity.
Cardiac: Distant heart sounds, murmur, rub.
Abdomen: Masses, tenderness, hepatomegaly, splenomegaly.
Extremities: Clubbing, edema.
Neurologic: Mental status, muscle tone and strength.
Laboratory Evaluation: CBC, electrolytes, BUN, creatinine; O2 saturation, liver
function tests; UA, early morning gastric aspirate to obtain swallowed sputum
for acid-fast bacilli stain and culture. Histological examination of lymph nodes,
pleura, liver, bone marrow biopsies.
Chest X-ray: Segmental consolidation, hilar node enlargement, segmental
atelectasis.
Differential Diagnosis: Atypical mycobacteria infection, active pulmonary
tuberculosis, latent tuberculosis.

Otitis Media
Chief Complaint: Ear pain.
History of Present Illness: Ear pain, fever, irritability. Degree of fever; time of
onset; cough, sore throat, headache, neck stiffness, diarrhea.
Past Medical History: Previous episodes of otitis media, pneumonia, asthma,
diabetes, immunosuppression, steroid use.
28 Pharyngitis

Allergies: Antibiotics.

Family History: Recurrent ear infections.

Physical Examination
Ears: Bulging, opacified, erythematous tympanic membrane; poor visualization
of landmarks, absent light reflex , retraction, decreased mobility with
insufflation of air.
Nose: Nasal discharge, erythema.

Throat: Pharyngeal erythema, exudate.

Chest: Breath sounds.

Heart: Rate and rhythm, murmurs.

Abdomen: Tenderness, hepatomegaly.

Laboratory Evaluation: CBC, electrolytes, tympanocentesis.

Differential Diagnosis: Acute otitis media, mastoiditis, otitis externa, otitis

media with effusion, cholesteatoma, tympanosclerosis, cholesteatoma.

Pharyngitis
Chief Complaint: Sore throat.
History of Present Illness: Sore throat, fever, cough, irritability, ear pain. Nasal
discharge, headache, abdominal pain; prior streptococcal pharyngitis, past
streptococcal pharyngitis, scarlet fever, rheumatic fever.
Past Medical History: Previous episodes of otitis media, pneumonia, asthma,
diabetes, immunosuppression.
Allergies: Antibiotics.
Family History: Streptococcal throat infections.

Physical Examination

General Appearance: Note whether the patient appears well or toxic.

Vital Signs: Temperature (fever), pulse, blood pressure, respiratory rate.

Skin: Rash ("sandpaper" feel, scarlet fever).

Lymph Nodes: Tender cervical adenopathy.

Ears: Tympanic membrane erythema, bulging.

Nose: Mucosal erythema.

Throat: Erythema, vesicles, ulcers, soft palate petechiae. Tonsillar exudate.

Mouth: Foul breath.

Abdomen: Tenderness (mesenteric adenitis), hepatomegaly, splenomegaly.

Clinical Manifestations of Pharyngitis

Group A streptococcus Viral (other than EBV) Epstein-Barr virus

Age Generally 3 years or older Any age Over 5 yrs (especially late school
age/adolescent)

Season Fall to spring Any Any

Clinical Tender cervical adenopathy, Papular-vesicular lesions or Indolent onset, tonsillar exudates,
foul breath, tonsillar tonsillar ulcers (eg, herpangina, lymphadenopathy, fatigue, hepato
exudates, soft palate Coxsackie A), URI symptoms. splenomegaly, atypical lymphocytes
petechiae, abdominal pain Rash, often papulosquamous. in peripheral smear. Rash with peni
(mesenteric adenitis), head cillin. Illness lasts more than 7-10
ache, rash ("sandpaper" feel, days (GABHS infection resolves
scarlet fever), no rhinorrhea, within 7 days).
no cough, conjunctivitis (ie,
no URI symptoms)
30 Peritonsillar, Retropharyngeal or Parapharyngeal Abscess

Laboratory Evaluation: Rapid antigen detection test, throat culture.

Differential Diagnosis of Pharyngitis: Viruses (influenza, adenovirus. Epstein-
Barr virus), groups C and G streptococci, Corynebacterium diphtheriae (gray
exudate in the pharynx), Chlamydia.

Peritonsillar, Retropharyngeal or Parapharyngeal

Abscess
Chief Complaint: Throat pain.
History of Present Illness: Recent tonsillopharyngitis or URI. Stridor,
dysphagia, drooling.
Past Medical History: Previous peritonsillar abscesses, pharyngitis, otitis
media, pneumonia, asthma, diabetes, immunosuppression.
Medications: Immunosuppressants.
Allergies: Antibiotics.
Family History: Streptococcal pharyngitis.

Physical Examination

General Appearance: Severe throat pain and dysphagia. Ill appearance.

Throat: Trismus, "hot potato voice," uvula pointing toward unaffected side

(peritonsillar abscess). Stridor, drooling, anterior pharyngeal wall displace

ment (retropharyngeal abscess).
Lymph Nodes: Cervical lymphadenopathy.
Chest: Breath sounds, rhonchi.
Heart: Murmurs, rubs.
Abdomen: Tenderness, hepatomegaly, splenomegaly.
Laboratory Evaluation: Cultures of surgical drainage. Lateral neck X ray.

Epiglottitis
Chief Complaint: Sore throat.
History of Present Illness: 3 to 7 years of age and an abrupt onset of high
fever, severe sore throat, dysphagia, drooling. Refusal to swallow, drooling;
quiet, hoarse voice.
Past Medical History: Immunosuppression.

Medications: Immunosuppressants.

Vaccinations: Haemophilus influenza immunization.

Physical Examination

General Appearance: Inspiratory stridor, toxic appearance. Respiratory

distress (sitting in tripod posture with neck extended), apprehension.

Chest: Stridor, decreased breath sounds.
Heart: Murmurs.
Abdomen: Tenderness, splenomegaly.
Extremities: Cyanosis.
Laboratory Evaluation: Lateral neck x-rays
 Croup 31

Differential Diagnosis of Epiglottitis

Epiglottitis Viral Laryngo Bacterial Tracheitis

tracheitis

High fever, dysphagia, Low-grade fever, coryza. Improving croup that

drooling, "toxic" ap barking cough, hoarse worsens; high fever,
pearance, refusal to voice stridor, anterior neck
speak tenderness: no drool
ing

Croup (Viral Laryngotracheobronchitis)

Chief Complaint: Cough.
History of Present Illness: Mild upper respiratory symptoms, followed by
sudden onset of a barking cough and hoarseness, often at night.
Past Medical History: Immunosuppression.
Past Medical History: Prematurity, respiratory distress syndrome,
bronchopulmonary dysplasia.
Medications: Antibiotics.
Vaccinations: Haemophilus influenza immunization.

Physical Examination
General Appearance: Low-grade fever, non-toxic appearance. Comfortable at
rest, barky, seal-like cough. Restlessness, altered mental status.
Vital Signs: Respirations (tachypnea), blood pressure, pulse (tachycardia),
temperature (low-grade fever).
Skin: Pallor, cyanosis.
Chest: Inspiratory stridor, tachypnea, retractions, diminished breath sounds.
Abdomen: Retractions, paradoxical abdominal wall motion (abdomen rises on
inspiration), tenderness.
Laboratory Evaluation: Anteroposterior neck radiographs: subglottic narrow
ing, ("steeple sign"); pulse oximetry.
Differential Diagnosis: Epiglottitis, acute croup, foreign body aspiration,
anaphylaxis; spasmodic croup (recurrent allergic upper airway spasm).

Bronchiolitis
Chief Complaint: Wheezing.
History of Present Illness: Duration of wheezing, cough, mild fever, nasal
discharge, congestion. Cold weather months. Oxygen saturation.
Past Medical History: Chronic pulmonary disease (ie, prematurity,
bronchopulmonary dysplasia), heart disease, immunocompromise.
Medications: Bronchodilators.
Allergies: Aspirin, food allergies.
Family History: Asthma, hayfever, eczema.
Social History: Exposure to passive cigarette smoke.
32 Meningitis

Physical Examination

General Appearance: Comfortable appearing, non-toxic.

Vital Signs: Temperature (low-grade fever), respirations, pulse, blood pressure.

Ears: Tympanic membrane erythema.

Nose: Rhinorrhea

Mouth: Flaring of the nostrils.

Chest: Chest wall retractions, wheezing, fine crackles on inspiration, diminished

air exchange.
Heart: Murmurs.
Abdomen: Paradoxical abdominal wall motion with respiration (ie, abdomen
collapses with each inspiration).
Laboratory Evaluation: CBC, electrolytes, pulse oximetry. Nasopharyngeal
washings for RSV antigen.
Chest X-ray: Hyperinflation, flattened diaphragms, patchy atelectasis.
Differential Diagnosis: Foreign body aspiration, asthma, pneumonia,
congestive heart failure, aspiration syndromes (gastroesophageal reflux).

Meningitis
Chief Complaint: Fever and lethargy.
History of Present Illness: Duration and degree of fever; headache, neck
stiffness, cough; lethargy, irritability (high-pitched cry), vomiting, anorexia,
rash.
Past Medical History: Pneumonia, otitis media, endocarditis. Diabetes, sickle
cell disease; recent upper respiratory infections. Travel history.
Perinatal History: Prematurity, respiratory distress.
Medications: Antibiotics.
Social History: Home situation.
Family History: Exposure to H influenza or neisseria meningitis.

Physical Examination
General Appearance: Level of consciousness; obtundation, labored respira
tions. Note whether the patient looks ill, well, or malnourished.
Vital Signs: Temperature (fever), pulse (tachycardia), respiratory rate
(tachypnea), BP (hypotension).
Skin: Capillary refill, rashes, petechia, purpura (meningococcemia).
Head: Bulging or sunken fontanelle.
Eyes: Extraocular movements, papilledema, pupil reactivity, icterus.
Neck: Nuchal rigidity. Brudzinski's sign (neck flexion causes hip flexion);
Kernig's sign (flexing hip and extending knee elicits resistance).
Chest: Rhonchi, crackles, wheeze.
Heart: Rate of rhythm, murmurs.
Extremities: Splinter hemorrhages (endocarditis).
Neurologic: Altered mental status, weakness, sensory deficits.
Laboratory Evaluation:
CSF Tube 1 - Gram stain, culture and sensitivity, bacterial antigen screen (1
2 mL).
CSF Tube 2 - Glucose, protein (1-2 mL).
CSF Tube 3 - Cell count and differential (1-2 mL).
Electrolytes, BUN, creatinine. CBC with differential, blood cultures, smears and
cultures from purpuric lesions: cultures of stool, urine, joint fluid, abscess;
 Urinary Tract Infection 33

purified protein derivative (PPD).

Cerebral Spinal Fluid Analysis

Disease Color Protein Cells Glucose

Normal CSF Fluid Clear <50 <5 >40 mg/100

mg/100 lymphs/mm3 mL, -2/3 of
mL blood glucose
level

Bacterial meningitis Cloudy Elevated >100 Low, < of

or tuberculous men 50-1500 WBC/mm3 blood
ingitis predomi glucose
nantly neutro
phils. Bacte
ria present on
Grams stain.

Tuberculous, fungal, Clear Elevated 10-500 WBC 20-40, low

partially treated bac opal usually with predomi
terial, syphilitic men escent <500 nant lymphs
ingitis, meningeal
metastases

Viral meningitis, par Clear Slightly 10-500 WBC Normal to low

tially treated bacte opal elevated with predomi
rial meningitis, en escent or nor nant lymphs
cephalitis, toxo mal
plasmosis

Urinary Tract Infection

Chief Complaint: Pain with urination.
History of Present Illness: Dysuria, frequency (voiding repeatedly of small
amounts), malodorous urine, incontinence; suprapubic pain, low-back pain,
fever, chills (pyelonephritis), vomiting, irritability; constipation. Urine culture
results (suprapubic aspiration or urethral catheterization).
Past Medical History: Urinary infections.

Signs and Symptoms of UTIs in Different Age Groups

Age Signs/Symptoms

Neo Hypothermia, hyperthermia, failure to thrive. vomiting,

nate/infant diarrhea, sepsis, irritability, lethargy, jaundice, mal
odorous urine

Toddler Abdominal pain, vomiting, diarrhea, constipation, abnor

mal voiding pattern, malodorous urine, fever, poor
growth
34 Lymphadenopathy and Lymphadenitis

Age Signs/Symptoms

School age Dysuria, frequency, urgency, abdominal pain,

incontinence or secondary enuresis, constipation, mal
odorous urine, fever

Adolescent Dysuria, frequency, urgency, abdominal pain, malodor

ous urine, fever

Physical Examination
General Appearance: Dehydration, septic appearance. Note whether the
patient looks toxic or well.
Vital Signs: Temperature (high fever [>38C] pyelonephritis), respiratory rate,
pulse, BP.
Chest: Breath sounds.
Heart: Rhythm, murmurs.
Abdomen: Suprapubic tenderness, costovertebral angle tenderness
(pyelonephritis), renal mass, nephromegaly. Lower abdominal mass
(distended bladder), stool in colon.
Pelvic/Genitourinary: Circumcision, hypospadia, phimosis, foreskin; vaginal
discharge.
Laboratory Evaluation: UA with micro, urine Gram stain, urine C&S. CBC with
differential, electrolytes. Ultrasound, voiding cystourethrogram, renal nuclear
scan.
Differential Diagnosis: Cystitis, pyelonephritis, vulvovaginitis, gonococcal or
chlamydia urethritis, herpes infection, cervicitis, appendicitis, pelvic inflamma
tory disease.

Differential Diagnosis of Urinary Tract Symptoms

Urinary tract infection Emotional disturbances

Urethritis Vulvovaginitis
Urethral irritation by soaps, deter Trauma (sexual abuse)
gents, bubble bath Pinworms
Vaginal foreign bodies

Lymphadenopathy and Lymphadenitis

Chief Complaint: Swollen lymph nodes.
History of Present Illness: Duration of generalized or regional adenopathy.
Fever, pattern, spiking fevers, relapsing fever, rash, arthralgias. Sore throat,
nasal discharge, cough, travel history. Animal exposure (cat scratch, kittens).
Localized trauma or skin infection, exposure to tuberculosis, blood product
exposure. Conjunctivitis, recurrent infections.
Past Medical History: Developmental delay, growth failure.
Social History: Intravenous drug use, high-risk sexual behavior.
 Lymphadenopathy and Lymphadenitis 35

Medications: Phenytoin.
Review of Systems: Weight loss, night sweats, bone pain. Pallor, easy
bruising.

Historical Evaluation of Lymphadenopathy

Generalized or regional adenopathy Animal exposure

Fever Blood product exposure
Rash Arthralgia/arthritis
Exposure to infection Delayed growth/development
Travel Weight loss, night sweats
Lesions at birth

Physical Examination
General Appearance: Dehydration, septic appearance. Note whether the
patient looks toxic or well.
Vital Signs: Temperature (fever), pulse (tachycardia), blood pressure, wide
pulse pressure (hyperthyroidism). Growth percentiles.
Lymph Nodes: Generalized or regional adenopathy. Location, size of enlarged
lymph nodes; discreteness, mobility, consistency, tenderness, fluctuation.
Supraclavicular or posterior triangle lymphadenopathy.
Skin: Lesion in the area(s) drained by affected lymph nodes. Sandpaper rash
(scarlet fever), punctums, pustules, splinter hemorrhages (endocarditis),
exanthems or enanthems, malar rash (systemic lupus erythematosus).
Eyes: Conjunctivitis, uveitis.

Chest: Breath sounds, wheeze, crackles.

Heart: Rhythm, murmurs.

Abdomen: Tenderness, masses, hepatomegaly splenomegaly.

Extremities: Joint swelling, joint tenderness, extremity lesions, nasopharyngeal

masses.

Physical Examination Findings in Lymphadenopathy

Generalized or regional Hepatosplenomegaly

adenopathy Skin pustule/puncture
Growth failure Conjunctivitis/uveitis
Fever Midline neck mass that retracts
Tachycardia, wide pulse pressure, with tongue protrusion
brisk reflexes Mass in posterior triangle
Rash/exanthem Supraclavicular mass
36 Lymphadenopathy and Lymphadenitis

Differential Diagnosis of Adenopathy Based on Location

Location of Node(s) Etiology of Infection or Process

Posterior auricular, posterior/ Measles, scalp infections (eg, tinea capitis)

suboccipital, occipital

Submandibular, anterior cervi Oropharyngeal or facial infections (unilateral,

cal "cold" submandibular nodes without infection
indicates atypical mycobacteria)

Preauricular Sinusitis, tularemia

Posterior cervical Adjacent skin infection

Bilateral cervical of marked Kawasaki's disease, mononucleosis,

degree toxoplasmosis, secondary syphilis

Supraclavicular or scalene, Infiltrative process (malignancy)

lower cervical

Axillary Cat scratch disease, sporotrichosis

Generalized adenopathy, in Generalized infection (mononucleosis, hepatitis),

cluding axillary, epitrochlear, immunodeficiency (HIV), sarcoidosis
inguinal

Recurrent episodes of adenitis Chronic granulomatous disease, immunodefi

ciency

Differential Diagnosis of Generalized Lymphadenopathy

Systemic Infections

Bacterial infections Tuberculosis

Scarlet fever Syphilis
Viral exanthems (eg, rubella or Toxoplasma organisms
rubeola) Brucella organisms
Epstein-Barr virus Histoplasmosis
Cytomegalovirus Coccidioidomycosis
Hepatitis virus Typhoid fever
Cat-scratch disease Malaria
Mycoplasma organisms Chronic granulomatous disease
Bacterial endocarditis HIV infection

Immune-Mediated Inflammatory Disorders

Systemic lupus erythematosus Kawasaki syndrome

Juvenile rheumatoid arthritis Hyper IgD syndrome
Serum sickness Hyper IgE syndrome

Storage Diseases
 Cellulitis 37

Gaucher disease Tangier disease

Niemann-Pick disease

Malignancies

Leukemia Histiocytosis X
Lymphoma X-linked lymphoproliferative
Neuroblastoma syndrome

Metabolic Disorders

Hyperthyroidism Adrenal insufficiency

Miscellaneous

Drug reactions (phenytoin, allopurinol) Sarcoidosis

Hemolytic anemias Sinus histiocytosis
Immunoblastic lymphadenopathy

Laboratory Evaluation: Throat culture, EBV, CMV, toxoplasmosis titers, CBC

and differential, ESR, PPD. Blood cultures, chest X ray, VDRL. Needle
aspiration of the node, after saline infusion, for Gram's stain and acid-fast
stains, and culture for aerobes, anaerobes, and mycobacteria. Cat scratch
bacillus (Bartonella henselae) titer.

Differential Diagnosis of Cervical Lymphadenopathy

Viral upper respiratory tract infection Systemic disorders

(EBV or CMV infection) Kawasaki syndrome
Suppurative infections (staphylococcal, Kikuchi disease
streptococcal) Hyper IgD syndrome
Cold inflammation Hyper IgE syndrome
Cat-scratch disease Sinus histiocytosis
Atypical mycobacterial adenitis Sarcoidosis
Toxoplasmosis Drugs

Cellulitis
Chief Complaint: Red skin lesion.
History of Present Illness: Warm, red, painful, indurated lesion. Fever, chills,
headache; diarrhea, localized pain, night sweats. Insect bite or sting; joint
pain.
Past Medical History: Cirrhosis, diabetes, heart murmur, recent surgery; AIDS
risk factors.
Allergies: Drug allergies.
Review of Systems: Animal exposure (pets), travel history, drug therapy.
Family History: Diabetes, cancer.
Social History: Home situation.

Physical Examination

General Appearance: Note whether the patient looks ill or well.

38 Infective Endocarditis

Vital Signs: Temperature (fever curve), respiratory rate (tachypnea), pulse

(tachycardia), BP (hypotension).
Skin: Warm, erythematous, tender, indurated lesion. Poorly demarcated
erythema with flat borders. Bullae, skin breaks, petechia, ecthyma
gangrenosum (purpuric of Pseudomonas), pustules, abscesses.
Lymph Nodes: Adenopathy localized or generalized lymphadenopathy.
HEENT: Conjunctival erythema, periodontitis, tympanic membrane inflamma
tion, neck rigidity.
Chest: Rhonchi, crackles, dullness to percussion (pneumonia).
Heart: Murmurs (endocarditis).
Abdomen: Liver tenderness, hepatomegaly, splenomegaly. Costovertebral
angle tenderness, suprapubic tenderness.
Extremities: Wounds, joint or bone tenderness (septic arthritis).
Laboratory Evaluation: CBC, ESR, blood cultures x 2, electrolytes, glucose,
BUN, creatinine, UA, urine Gram stain, C&S; skin lesion cultures. Needle
aspiration of border for Gram's stain and culture. Antigen detection studies.
Differential Diagnosis: Cellulitis, erysipelas, dermatitis, dermatophytosis.

Infective Endocarditis
Chief Complaint: Fever
History of Present Illness: Chronic fever, murmur, malaise, anorexia, weight
loss, arthralgias, abdominal pain. Recent gastrointestinal procedure, urinary
procedure, dental procedure. valvular disease, rheumatic fever, seizures,
stroke.
Past Medical History: Congenital heart disease.

Physical Examination

General Appearance: Note whether the patient looks toxic or well.

Vital Signs: Blood pressure (hypotension), pulse (tachycardia), temperature

(fever), respirations (tachypnea).

Eyes: Roth spots (white retinal patches with surrounding hemorrhage)
Chest: Crackles, rhonchi.
Heart: Regurgitant murmurs.
Skin: Petechiae, Janeway lesions, Osler's nodes, splinter hemorrhages.
Extremities: Edema, clubbing.
Abdomen: Hepatomegaly, splenomegaly, tenderness.
Neurologic: Weakness, sensory deficits.
Laboratory Studies: CBC (leukocytosis with left shift), ESR, CXR, ECG, blood
cultures, urinalysis and culture, BUN/creatinine, cultures of intravenous lines
and catheter tips; echocardiography.
Differential Diagnosis: Infective endocarditis, rheumatic fever, systemic
infection, tuberculosis, urinary tract infection.
 Septic Arthritis 39

Septic Arthritis
Chief Complaint: Joint pain.
History of Present Illness: Joint pain and warmth, redness, swelling,
decreased range of motion. Acute onset of fever, limp, or refusal to walk.
Penetrating injuries or lacerations. Preexisting joint disease (eg, rheumatoid
arthritis), prosthetic joint; sexually transmitted disease exposure.
Past Medical History: H. influenzae immunization, sickle cell anemia, M.
tuberculosis exposure.

Physical Examination
General Appearance: Note whether the patient looks toxic or well.
Vital Signs: Temperature (fever), blood pressure (hypotension), pulse
(tachycardia), respirations.
Skin: Erythema, skin puncture. Vesicular rash, petechia.
HEENT: Neck rigidity.
Chest: Crackles, rhonchi.
Heart: Murmurs, friction rub.
Abdomen: Tenderness, hepatomegaly, splenomegaly.
Extremities: Erythema, limitation in joint range of motion, joint tenderness,
swelling. Refusal to change position.
Laboratory Evaluation: X-rays of joint (joint space distention, periosteal
reaction), CT or MRI. Arthrocentesis for cell count, Gram's stain, glucose,
mucin clot, cultures. Bone-joint scans (gallium, technetium). Blood cultures.
Culture of cervix and urethra on Thayer-Martin media for gonorrhea. Lyme
titer, anti-streptolysin-O titer.

Synovial Fluid Findings in Various Types of Arthritis

WBC Count/mm3 % PMN Joint Fluid:Blood

Glucose Ratio

Septic arthritis >50,000 90 Decreased

Juvenile rheuma <15,000-20,000 60 Normal to

toid arthritis decreased

Lyme arthritis 15,000-100,000 50+ Normal

Differential Diagnosis: Septic arthritis, Lyme disease, juvenile rheumatoid

arthritis, systemic lupus erythematosus, acute rheumatic fever, inflammatory
bowel disease, leukemia (bone pain), synovitis, trauma, cellulitis.

Osteomyelitis
Chief Complaint: Leg pain.
History of Present Illness: Extremity pain, degree of fever, duration of fever,
limitation of extremity use; refusal to use the extremity or bear weight. Hip
pain, abdominal pain, penetrating trauma, dog or cat bite (Pasteurella
multocida), human bites, immunocompromise, tuberculosis.
40 Osteomyelitis

Past Medical History: Diabetes mellitus, sickle cell disease; surgery, prosthetic
devices.
Medications: Immunosuppressants.
Social History: Intravenous drug abuse.

Physical Examination
General Appearance: Note whether the patient looks septic or well.
Vital Signs: Blood pressure (hypotension), pulse (tachycardia), temperature
(fever), respirations (tachypnea).
Skin: Petechiae, cellulitis, rash.
Chest: Crackles, rhonchi.
Heart: Regurgitant murmurs.
Extremities: Point tenderness, swelling, warmth, erythema. Tenderness of
femur, tibia, humerus.
Back: Tenderness over spinus processes.
Abdomen: Tenderness, rectal mass.
Feet: Puncture wounds.
Laboratory Evaluation: CBC (elevated WBC), ESR (>50), blood culture; X-rays
(soft tissue edema), CT or MRI. Technetium bone scan.
Differential Diagnosis: Cellulitis, skeletal or blood neoplasia (Ewing's sarcoma,
leukemia), bone infarction (hemoglobinopathy), hemophilia with bleeding,
thrombophlebitis, child abuse/trauma, synovitis.
 Acute Abdominal Pain and the Acute Abdomen 41

Gastrointestinal Disorders

Acute Abdominal Pain and the Acute Abdomen

Chief Complaint: Abdominal pain.
History of Present Illness: Duration of pain, location of pain; characteristics of
pain (diffuse, burning, crampy, sharp, dull); constant or intermittent; fre
quency. Effect of eating, defecation, urination, movement. Characteristics of
last bowel movement. Relation to last menstrual period.
Relationship to meals. What does the patient do when the pain occurs? Fever,
chills, nausea, vomiting (bilious, undigested food, blood, sore throat,
constipation, diarrhea, hematochezia, melena, anorexia, weight loss.
Past Medical History: Diabetes, asthma, prematurity, surgery. Endoscopies,
X-rays.
Medications: Aspirin, NSAIDs, narcotics, anticholinergics, laxatives.
Family History. Abdominal pain in family members, peptic ulcer disease,
irritable bowel syndrome.
Social History: Recent travel, change in food consumption, drugs or alcohol.
Review of Systems: Growth delay, weight gain, emesis, bloating, distension.
Headache, fatigue, weakness, stress- or tension-related symptoms.

Physical Examination
General Appearance: Degree of distress, body positioning to relieve pain,
nutritional status. Signs of dehydration, septic appearance.
Vitals: Temperature (fever), pulse (tachycardia), BP (hypertension,
hypotension), respiratory rate and pattern (tachypnea).
Skin: Jaundice, petechia, pallor, rashes.
HEENT: Pale conjunctiva, pharyngeal erythema, pus, flat neck veins.
Lymph Nodes: Cervical axillary, periumbilical, inguinal lymphadenopathy,
Virchow node (supraclavicular mass).
Abdomen
Inspection: Distention, visible peristalsis (small bowel obstruction).
Auscultation: Absent bowel sounds (late obstruction), high-pitched rushes
(early obstruction), bruits.
Palpation: Masses, hepatomegaly, liver texture (smooth, coarse),
splenomegaly. Bimanual palpation of flank, nephromegaly. Rebound
tenderness, hernias, (inguinal, femoral, umbilical); costovertebral angle
tenderness. Retained fecal material, distended bladder (obstructive
uropathy).
McBurney's Point Tenderness: Located two-thirds of the way between
umbilicus and anterior superior iliac spine (appendicitis).
Iliopsoas Sign: Elevation of legs against examiner's hand causes pain,
retrocecal appendicitis. Obturator sign: Flexion of right thigh and
external rotation of thigh causes pain in pelvic appendicitis.
Rovsing's Sign: Manual pressure and release at left lower quadrant
causes referred pain at McBurney's point (appendicitis).
Percussion: Liver and spleen span, tympany.
Rectal Examination: Impacted stool, masses, tenderness; gross or occult
blood.
Perianal Examination: Fissures, fistulas, hemorrhoids, skin tags, soiling (fecal
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 Psychogenic Causes

Antral gastritis, peptic ulcer Conversion reaction
Constipation Somatization disorder
Crohn disease Anxiety disorder
Carbohydrate malabsorption Other Causes
Pancreatitis Intervertebral disk disease
Cholelithiasis Spine disease
Malrotation and volvulus Musculoskeletal trauma
Intestinal parasitic infection (G. Migraine or cyclic vomiting
lamblia) Abdominal epilepsy
Urinary Tract Disorders
Ureteropelvic junction obstruction
Urinary tract infection
Urolithiasis

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.
 Persistent Vomiting 45

Historical Findings in Persistent Vomiting

Appearance of Vomitus Other Gastrointestinal

Large volume, bilious Symptoms
Uncurdled milk, food Nausea
Bile Swallowing difficulties
Feculent emesis Constipation
Bloody, coffee-grounds Pain
Character of Emetic Act Jaundice
Effortless, nonbilious Neurologic Symptoms
Tongue thrusting Headache
Finger sucking, gagging Seizures
Projectile vomiting General
Timing of Emesis Respiratory distress
Early morning Travel, animal/pet exposure
Related to meals or foods Ill family members
Stress

Physical Examination
General Appearance: Signs of dehydration, septic appearance. Note whether
the patient looks ill or well.
Vital Signs: BP (hypotension, hypertension), pulse (tachycardia), respiratory
rate, temperature (fever). Growth percentiles.
Skin: Pallor, jaundice, flushing, rash.
HEENT: Nystagmus, papilledema; ketone odor on breath (apple odor, diabetic
ketoacidosis); jugular venous distention. Bulging fontanelle, papilledema.
Lungs: Wheezes, rhonchi, rales.
Abdomen: Tenderness to percussion, distention, increased bowel sounds,
rebound tenderness (peritonitis). Nephromegaly, masses, hepatomegaly,
splenomegaly, costovertebral angle tenderness.
Extremities: Edema, cyanosis.
Genitourinary: Adnexal tenderness, uterine enlargement.
Rectal: Perirectal lesions, localized tenderness, masses, occult blood.
Neurologic Examination: Strength, sensation, posture, gait, deep tendon
reflexes.

Physical Examination Findings in Persistent Vomiting

Vital Signs: Tachycardia, bradycardia, Genitourinary System

tachypnea, fever, hypotension, hy Adnexal pain
pertension, short stature, poor weight Mass
gain Rectal mass
Abdomen Respiratory: Bronchospasm, pneumo
Distension nia
Absent bowel sounds Neurologic: Migraine, seizures, in
Increased bowel sounds creased intracranial pressure
Rebound tenderness Renal: Flank pain
Masses Skin: Rash, purpura

Laboratory Evaluation: CBC, electrolytes, UA, amylase, lipase, LFTs,

pregnancy test, abdominal X-ray series.
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, stenosis, vascular ring, tracheal
esophageal fistula, cricopharyngeal incoordination, achalasia, natal hernia,
diaphragmatic hernia
Torsion of the stomach
Malrotation of the bowel
Volvulus
Intestinal atresia, stenosis, meconium ileus with cystic fibrosis, meconium plug
Webs
Annular pancreas
Paralytic ileus (peritonitis, postoperative, acute infection, hypokalemia)
Hirschsprung disease
Imperforate anus
Enteric duplication

Other gastrointestinal causes: Necrotizing enterocolitis, congenital lactose

intolerance, milk-soy protein intolerance, lactobeazor, GI perforation,
hepatitis, pancreatitis
Neurologic: Increased intracranial pressure, subdural hydrocephalus, edema,
kernicterus
Renal: Obstructive uropathy, renal insufficiency
Infection: Systemic infections, pyelonephritis
Metabolic: Urea cycle deficiencies, aminoacidopathies, disorders of carbohydrate
metabolism, acidosis, congenital adrenal hyperplasia, tetany, hypercalcemia
Drugs/toxins: Theophylline, caffeine, digoxin
Blood: Swallowed maternal blood, gastritis, ulcers
Pneumonia
Dysautonomia
Postoperative anesthesia
 Persistent Vomiting 47

Differential Diagnosis of Vomiting in Infants 2 Weeks to 12 Months

of Age

Gastroesophageal reflux, esophagitis

Functional
Innocent
Improper formula preparation
Aerophagia
Postcibal handling
Nervous
Rumination
Esophageal: Foreign body, stenosis, vascular ring, tracheoesophageal fistula
cricopharyngeal incoordination, achalasia, hiatal hernia
Stomach: Bezoar, lactobeazor
Intestinal obstruction, pyloric stenosis, malrotation, Meckel diverticulitis,
intussusception, incarcerated hernia, Hirschsprung disease, appendicitis, intestinal
duplications

Other gastrointestinal causes: Annular pancreas, paralytic ileus, hypokalemia,

Helicobacter sp. infection, peritonitis, pancreatitis, celiac disease, viral and
bacterial enteritis, lactose intolerance, milk-soy protein intolerance, cholecystitis,
gallstones, pseudo-obstruction
Neurologic: Increased intracranial (subdural hematoma, hydrocephalus, cerebral
edema)
Renal: Obstructive uropathy, renal insufficiency, stones
Infectious: Meningitis, sepsis, pyelonephritis, otitis media, sinusitis, pertussis,
hepatitis, parasitic infestation
Metabolic: Urea cycle deficiencies, aminoacidopathies, disorder of carbohydrate
metabolism, acidosis, congenital adrenal hyperplasia, tetany, hypercalcemia
Drugs/toxins: Theophylline, digoxin, iron, ipecac
Blood
Hydrometrocolpos
Radiation/chemotherapy
Reye syndrome
Psychogenic vomiting
Munchausen syndrome by proxy
48 Jaundice and Hepatitis

Differential Diagnosis of Vomiting in Children Older Than 12 Months

of Age

Gastroesophageal reflux
Gastrointestinal obstruction
Esophagea: Esophagitis, foreign body, corrosive ingestion, hiatal hernia
Stomach: Foreign body, bezoar, chronic granulomatous disease
Intestinal obstruction: Pyloric channel ulcer, intramural hematoma, malrotation,
volvulus, Meckel diverticulitis, meconium ileus in cystic fibrosis, incarcerated
hernia, intussusception, Hirschsprung disease, ulcerative colitis, Crohn
disease, superior mesenteric artery syndrome
Other gastrointestinal causes: Annular pancreas, paralytic ileus, hypokalemia,
Helicobacter pylori infection, peritonitis, pancreatitis, celiac disease, viral or
bacterial enteritis, hepatobiliary disease, gallstone ileus, Henoch-Schnlein
purpura.
Neurologic: Increased intracranial pressure, Leigh disease, migraine, motion
sickness, seizures
Renal: Obstructive uropathy, renal insufficiency, stones
Infection: Meningitis, sepsis, pyelonephritis, otitis media, sinusitis, hepatitis, parasitic
infestation, streptococcal pharyngitis, labyrinthitis
Metabolic: Inborn errors of metabolism, acidosis, diabetic ketoacidosis, adrenal
insufficiency
Drugs/toxins: Aspirin, digoxin, iron, lead, ipecac, elicit drugs
Torsion of the testis or ovary
Blood
Radiation/chemotherapy
Reye syndrome
Postoperative vomiting
Cyclic vomiting
Pregnancy
Psychologic: Bulimia nervosa, anorexia nervosa, stress, Munchausen syndrome by
proxy

Jaundice and Hepatitis

Chief Complaint: Jaundice.
History of Present Illness: Timing, progression, distribution of jaundice.
Abdominal pain, anorexia, vomiting, fever, dark urine, pruritus, arthralgias,
rash, diarrhea. Gradual, caudal progression of jaundice (physiologic jaundice
or breast-feeding jaundice), blood products, raw shellfish, day care centers,
foreign travel.
Past Medical History: Hepatitis serologies, liver function tests, liver biopsy,
hepatitis immunization.
Perinatal History: Course of the pregnancy, illnesses, infections, medications
taken during the pregnancy. Inability to pass meconium (cystic fibrosis),
failure to thrive, irritability. Newborn hypoglycemia, lethargy after the first
formula feedings (carbohydrate metabolic disorders).
Medications: Acetaminophen, isoniazid, phenytoin.
Family History: Liver disease, familial jaundice, lung disease, alpha1-antitrypsin
deficiency. History of perinatal infant death (metabolic disorders).
Social History: IV drug abuse, alcohol, exposure to hepatitis.
 Jaundice and Hepatitis 49

Historical Findings in Jaundice

Neonate Older Child

Family history: Familial jaundice, Acute illness

emphysema, infant deaths Failure to thrive
Prenatal history: Infection in Family history of jaundice
pregnancy, maternal risk Exposure: Blood products, raw
for hepatitis, medications shellfish, travel, drug abuse
Perinatal history:
Hypoglycemia, vomiting, leth
argy with feedings, failure to
pass meconium,
icterus, acholic stools.

Physical Examination

General Appearance: Signs of dehydration, septic appearance, irritability. Note

whether the patient looks ill or well.

Vital Signs: Pulse, BP, respiratory rate, temperature (fever).
Skin: Ecchymoses, excoriations, jaundice, urticaria, bronze discoloration
(hemochromatosis), diffuse rash (perinatal infection). Malar rash, discord
lesions (lupus), erythematous scaling papules (cystic fibrosis).
Lymph Nodes: Cervical or inguinal lymphadenopathy.
Head: Cephalohematoma, hypertelorism, high forehead, large fontanelle,
pursed lips (Zellweger syndrome), microcephaly.
Eyes: Scleral icterus, cataracts, Kayser-Fleischer rings (bronze corneal
pigmentation, Wilson's disease), xanthomas (chronic liver disease).
Mouth: Sublingual jaundice.
Heart: Rhythm, murmurs.
Chest: Gynecomastia, breath sounds.
Abdomen: Bowel sounds, bruits, right upper quadrant tenderness; liver span,
hepatomegaly; liver margin texture (blunt, irregular, firm, smooth),
splenomegaly; ascites.
Extremities: Joint tenderness, joint swelling, palmar erythema, edema,
anasarca. Jaundice, erythematous nodules over shins (erythema nodosum).
Neurologic: Lethargy, hypotonia, neuromuscular deficits.
Rectal: Perianal skin tags (inflammatory bowel disease), hemorrhoids, occult
blood.

Laboratory Evaluation of Jaundice

Screening Labs
Complete blood count, platelets, differential, smear
AST, ALT, GGT, alkaline phosphatase
Total and fractionated bilirubin
Protein, albumin levels
INR, PTT
Stool color
50 Jaundice and Hepatitis

Assessment Labs
Infection
Cultures of blood, urine, cerebrospinal fluid
Serologies: Toxoplasmosis, rubella, cytomegalovirus, herpes, hepatitis
panel, syphilis, 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, urinary copper excretion
Toxicology screen
Structural
24-hour duodenal intubation for bilirubin excretion
Ultrasound
Radionuclide or hepatobiliary scan
Operative cholangiogram
Autoimmune/inflammatory: ESR, ANA

Pathologic Diagnosis
Liver biopsy
Bone marrow biopsy (enzyme deficiency, hemoglobinopathies, hemolytic
anemias)
 Jaundice and Hepatitis 51

Differential Diagnosis of Neonatal Jaundice

Nonpathologic Causes Conjugated hyperbilirubinemia (con

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

Differential Diagnosis of Jaundice in Older Children

Metabolic/Genetic Infections (continued)

Gilbert syndrome Viral
Dubin-Johnson syndrome Herpes simplex virus
Rotor syndrome Varicella-zoster virus
Cystic fibrosis Adenovirus
Indian childhood cirrhosis Enterovirus
Wilson disease Rubella virus
Tyrosinemia Arbovirus
Alpha -antitrypsin deficiency HIV
1 Echovirus
Anatomic Bacterial
Caroli disease Sepsis
Congenital hepatic fibrosis Toxic shock syndrome
Choledochal cyst Lyme disease
Cholelithiasis Rocky mountain spotted
Pancreas and pancreatic duct fever
abnormalities Miscellaneous
Infections Visceral larval migrans
Viral Schistosomiasis
Hepatitis (A, B, C, D, E), CMV Reye syndrome
Epstein-Barr virus

Hepatosplenomegaly
Chief Complaint: Liver or spleen enlarged.
History of Present Illness: Duration of enlargement of the liver or spleen.
Acute or chronic illness, fever, jaundice, pallor, bruising, weight loss, fatigue,
joint pain, joint stiffness. Nutritional history, growth delay.
Neurodevelopmental delay or loss of developmental milestones.
Past Medical History: Previous organomegaly, neurologic symptoms. General
health.
Perinatal History: Prenatal complications, neonatal jaundice.
Medications: Current and past drugs, anticonvulsants, toxins.
Family History: Storage diseases, metabolic disorders, hepatic fibrosis, alpha1
antitrypsin deficiency. History of neonatal death.
Social History: Infections, toxin, exposures, drugs or alcohol.

Physical Examination

General Appearance: Wasting, ill appearance, malnutrition.

Vital Signs: Blood pressure, temperature, pulse, respirations. Growth curve.

HEENT: Head size and shape, icterus, cataracts (galactosemia), Kayser-

Fleischer rings (Wilson disease). Coarsening of facial features

(mucopolysaccharidoses).
Skin: Excoriations, spider angiomas (chronic liver disease, bilary obstruction of
the biliary tract); pallor, petechiae, bruising (malignancy, chronic liver
disease); erythema nodosum (inflammatory bowel disease, sarcoidosis).
Lymph Nodes: Location and size of lymphadenopathy.

Lungs: Crackles, wheeze, rhonchi.

Abdomen: Distension, prominent superficial veins (portal hypertension), umbili

cal hernia, bruits. Percussion of flanks for shifting dullness. Liver span by
 Hepatosplenomegaly 53

percussion, hepatomegaly. Liver consistency and texture. Spleen size and

texture, splenomegaly.
Perianal: Hemorrhoids (portal hypertension), fissures, skin tags, fistulas
(inflammatory bowel disease).
Rectal Exam: Masses, tenderness.
Extremities: Edema, joint tenderness, joint swelling, joint erythema (juvenile
rheumatoid arthritis, mucopolysaccharidoses). Clubbing (hypoxia, intestinal
disorders, hepatic disorders).

Physical Examination Findings in Hepatosplenomegaly

Growth curve failure

Skin: Icterus, pallor, edema, pruritus, spider nevi, petechiae and bruises, rashes
Head--microcephaly or macrocephaly
Eyes--cataracts (galactosemia); Kayser-Fleischer rings (Wilson disease)
Nodes--generalized lymphadenopathy
Chest--adventitious sounds
Heart--gallop, tachycardia, rub, pulsus paradoxus
Abdomen--ascites, large kidneys, prominent veins, hepatosplenomegaly
Rectal--hemorrhoids, sphincter tone, fissures, fistulas, skin tags with inflammatory
bowel disease
Neurologic-- developmental delay, dystonia, tremor, absent reflexes, ataxia

Differential Diagnosis of Hepatosplenomegaly

Predominant Splenomegaly Predominant Hepatomegaly

Infection CMV, syphilis, neonatal hepatitis

ViralEpstein-Barr, cytomegalovirus, Hepatitis--A, B, C, D, E, tuberculosis,
parvovirus B19 sarcoidosis, chronic granulomatous dis
Bacterial--endocarditis, shunt infec ease
tion Drugs--alcohol, phenytoin
Protozoal--malaria, babesiosis Sclerosing cholangitis, infectious
Hematologic cholangitis
Hemolytic anemias Abscess
Porphyrias Chronic active hepatitis
Osteopetrosis, myelofibrosis Cardiac--failure, pericarditis
Vascular Budd-Chiari syndrome
Portal vein anomalies Paroxysmal nocturnal hemoglobinuria
Hepatic scarring or fibrosis Biliary atresia or hypoplasia
Tumor and infiltration Choledochal cyst
Cysts, hemangiomas, hamartomas Congenital hepatic fibrosis
Lymphoreticular malignancies Child abuse--trauma
Neuroblastoma Galactosemia, glycogen storage disease,
fructose intolerance
Tyrosinemia, urea cycle disorders
Cystic fibrosis
Alpha -antitrypsin deficiency
1
Wilson disease, hemochromatosis
Fatty change: Malnutrition, obesity, alco
hol, corticosteroids, diabetes
Primary or metastatic tumors
54 Acute Diarrhea

Acute Diarrhea
Chief Complaint: Diarrhea.
History of Present Illness: Duration and frequency, of diarrhea; number of
stools per day, characteristics of stools (bloody, mucus, watery, formed, oily,
foul odor); fever, abdominal pain or cramps, flatulence, anorexia, vomiting.
Season (rotavirus occurs in the winter). Amount of fluid intake and food
intake.
Past Medical History: Recent ingestion of spoiled poultry (salmonella), spoiled
milk, seafood (shrimp, shellfish; Vibrio parahaemolyticus); common food
sources (restaurants), travel history. Ill contacts with diarrhea, sexual
exposures.
Family History: Coeliac disease.
Medications Associated with Diarrhea: Magnesium-containing antacids,
laxatives, antibiotics.
Immunizations: Rotavirus immunization.

Physical Examination
General Appearance: Signs of dehydration. Note whether the patient looks
septic, well, or malnourished.
Vital Signs: BP( hypotension), pulse (tachycardia), respiratory rate, tempera
ture (fever).
Skin: Turgor, delayed capillary refill, jaundice.
HEENT: Dry mucous membranes.
Chest: Breath sounds.
Heart: Rhythm, gallops, murmurs.
Abdomen: Distention, high-pitched rushes, tenderness, splenomegaly,
hepatomegaly.
Extremities: Joint swelling, edema.
Rectal: Sphincter tone, guaiac test.
Laboratory Evaluation: Electrolytes, CBC with differential. Gram's stain of stool
for leukocytes. Cultures for enteric pathogens, stool for ova and parasites x
3; stool and blood for clostridium difficile toxin; blood cultures.
Stool occult blood. Stool cultures for cholera, E. coli 0157:H7, Yersinia; rotavirus
assay.
Differential Diagnosis of Acute Diarrhea: Rotavirus, Norwalk virus, salmo
nella, shigella, E coli, Campylobacter, Bacillus cereus, traveler's diarrhea,
antibiotic-related diarrhea.

Chronic Diarrhea
Chief Complaint: Diarrhea.
History of Present Illness: Duration, frequency, and timing of diarrheal
episodes. Volume of stool output (number of stools per day). Effect of fasting
on diarrhea. Prior dietary manipulations and their effect on stooling. Formula
changes, fever, abdominal pain, flatulence, tenesmus (painful urge to
defecate), anorexia, vomiting, myalgias, arthralgias, weight loss, rashes.
Stool Appearance: Watery, formed, blood or mucus, oily, foul odor.
Travel history, laxative abuse, inflammatory bowel disease. Sexual exposures,
AIDS risk factors. Exacerbation by stress.
Past Medical History: Pattern of stooling from birth. Growth deficiency, weight
 Chronic Diarrhea 55

gain. Three-day dietary record, ill contacts.

Medications and Substances Associated with Diarrhea: Laxatives,
magnesium-containing antacids, cholinergic agents, milk (lactase deficiency),
gum (sorbitol).
Family History: Family members with diarrhea, milk intolerance, coeliac
disease.
Social History: Water supply, meal preparation, sanitation, pet or animal
exposures.

Historical Findings in Chronic Diarrhea

Age of onset Secretory symptoms: Large volume,

Stool characteristics watery diarrhea
Diet (new food/formula) Osmotic symptoms: Large numbers of
Growth delay soft stools
Family history of allergy; genetic, meta Systemic symptoms: Fever, nausea,
bolic, or inborn errors malaise

Physical Examination
General Appearance: Signs of dehydration or malnutrition. Septic appearance.
Note whether the patient looks ill, well, or malnourished.
Vital Signs: Growth percentiles, pulse (tachycardia), respiratory rate, tempera
ture (fever), blood pressure (hypertension, neuroblastoma; hypotension,
dehydration).
Skin: Turgor, delayed capillary refill, jaundice, pallor (anemia), hair thinning,
rashes, erythema nodosum, pyoderma gangrenosum, maculopapular rashes
(inflammatory bowel disease), hyperpigmentation (adrenal insufficiency).
Eyes: Bitot spots (vitamin A deficiency), adenopathy.
Mouth: Oral ulcers (Crohn disease, coeliac disease), dry mucous membranes;
cheilosis (cracked lips, riboflavin deficiency); glossitis (B12, folate deficiency);
oropharyngeal candidiasis (AIDS).
Lymph Nodes: Cervical, axillary, inguinal lymphadenopathy.
Chest: Thoracic shape, crackles, wheezing.
Abdomen: Distention (malnutrition), hyperactive, bowel sounds, tenderness,
masses, palpable bowel loops, palpable stool. Hepatomegaly, splenomegaly.
Extremities: Joint tenderness, swelling (ulcerative colitis); gluteal wasting
(malnutrition), dependent edema.
Genitalia: Signs of child abuse or sexual activity.
Perianal Examination: Skin tags and fistulas.
Rectal: Perianal or rectal ulcers, sphincter tone, tenderness, masses, impacted
stool, occult blood, sphincter reflex.
Neurologic: Mental status changes, peripheral neuropathy (B6, B12 deficiency),
decreased perianal sensation. Ataxia, diminished deep tendon reflexes,
decreased proprioception.
56 Chronic Diarrhea

Physical Examination Findings in Chronic Diarrhea

Poor growth Clubbing

Hypertension Lung crackles, wheezing
Fever Abdominal mass
Jaundice Organomegaly
Rash Abnormal genitalia
Erythema nodosum Perianal tags
Pyoderma gangrenosa Rectal impaction
Edema Ataxia, decreased deep tendon reflexes

Laboratory Evaluation: Electrolytes, CBC with differential. Wright's stain for

fecal leucocytes; cultures for enteric pathogens, ova and parasites x 3;
clostridium difficile toxin. Stool carbohydrate content. Stool for occult blood,
neutral fat (maldigestion); split fat (malabsorption).

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
 Constipation 57

Constipation
Chief Complaint: Constipation.
History of Present Illness: Stool frequency, consistency, size; stooling pattern
birth to the present. Encopresis, bulky, fatty stools, foul odor. Hard stools,
painful defecation, straining, streaks of blood on stools. Dehydration, urinary
incontinence, enuresis. Abdominal pain, fever. Recent change in diet. Soiling
characteristics and time of day. Are stools formed or scybalous (small, dry,
rabbit-like pellets)? Withholding behavior.
Dietary History: Excessive cow's milk or limited fiber consumption; breast
feeding.
Past Medical History: Recent illness, bed rest, fever.
Medications Associated with Constipation: Opiate analgesics, aluminum
containing antacids, iron supplements, antihistamines, antidepressants.
Social History: Recent birth of a sibling, emotional stress, housing move.
Family History: Constipation.

Physical Examination
General Appearance: Dehydration or malnutrition. Septic appearance, weak
cry. Note whether the patient looks ill, well, or malnourished.
Vital Signs: BP (hypertension, pheochromocytoma), pulse, respiratory rate,
temperature. Growth percentiles, poor growth.
Skin: Caf au lait spots (neurofibromatosis), jaundice.
Eyes: Decreased pupillary response, icterus.
Mouth: Cheilosis (cracked lips, riboflavin deficiency), oral ulcers (inflammatory
bowel, coeliac disease), dry mucous membranes, glossitis (B12, folate
deficiency), oropharyngeal candidiasis (AIDS).
Abdomen: Distention, peristaltic waves, weak abdominal musculature
(muscular dystrophy, prune-belly syndrome). Hyperactive bowel sounds,
tenderness, hepatomegaly. Palpable stool, fecal masses above the pubic
symphysis and in the left lower quadrant.
Perianal: Anterior ectopic anus, anterior anal displacement. Anal fissures, ex
coriation, dermatitis, perianal ulcers. Rectal prolapse. Soiling in the perianal
area. Sphincter reflex: Gentle rubbing of the perianal skin results in reflex
contraction of the external anal sphincter.
Rectal: Sphincter tone, rectal ulcers, tenderness, hemorrhoids, masses. Stool
in a cavernous ampulla, occult blood.
Extremities: Joint tenderness, joint swelling (ulcerative colitis).
Neurologic: Developmental delay, mental retardation, peripheral neuropathy
(B6, B12 deficiency), decreased perianal sensation.
Laboratory Evaluation: Electrolytes, CBC with differential, calcium.
Abdominal X-ray: Air fluid levels, dilation, pancreatic calcifications.
58 Hematemesis and Upper Gastrointestinal Bleeding

Differential Diagnosis of Constipation in Neonates and Young

Infants

Meconium ileus Hirschsprung disease

Meconium plug syndrome Acquired aganglionosis
Functional ileus of the newborn Tumors
Small left colon syndrome Myelodysplasia
Volvulus Hypothyroidism
Intestinal web Maternal opiates
Intestinal stenosis Inadequate nutrition/fluids
Intestinal atresia Excessive cows milk consumption
Intestinal stricture (necrotizing Absence of abdominal musculature
enterocolitis) (prune-belly syndrome)
Imperforate anus Cerebral palsy
Anal stenosis
Anterior ectopic anus
Anterior anal displacement

Differential Diagnosis of Constipation in Older Infants and Children

Physiologic Causes Endocrine and Metabolic Disorders

Breast milk, cow's milk, low roughage Hypothyroidism
Deficient fluid: Fever, heat, immobility, Diabetes mellitus
anorexia nervosa Pheochromocytoma
Voluntary Stool Withholding Hypokalemia
Megacolon Hypercalcemia
Painful defecation: Anal fissure, Hypocalcemia
perianal dermatitis, hemorrhoids Diabetes insipidus
Behavioral issues Renal tubular acidosis
Mental retardation Porphyria
Neurogenic Disorders Amyloidosis
Hirschsprung disease Lipid storage disorders
Intestinal pseudoobstruction Miscellaneous Disorders
Cerebral palsy Anal or rectal stenosis
Myelomeningocele Anteriorly placed anus
Spinal cord injury Appendicitis
Transverse myelitis Celiac disease
Spinal dysraphism Scleroderma
Neurofibromatosis Lead poisoning
Myopathies Viral hepatitis
Rickets Salmonellosis
Prune-belly syndrome Tetanus
Chagas disease
Drugs

Hematemesis and Upper Gastrointestinal Bleed

ing
Chief Complaint: Vomiting blood.
History of Present Illness: Duration and frequency of hematemesis, character
istics of vomitus (bright red blood, coffee ground material), volume of blood,
hematocrit. Forceful retching prior to hematemesis (Mallory-Weiss tear).
 Hematemesis and Upper Gastrointestinal Bleeding 59

Abdominal pain, melena, hematochezia; peptic ulcer, prior bleeding episodes,

nose bleeds. Weight loss, anorexia, jaundice; bright red foods, drinks.
Past Medical History: Diabetes, bleeding disorders, renal failure, liver disease.
Gastrointestinal surgery.
Medications: Alcohol, aspirin, nonsteroidal anti-inflammatory drugs, anticoagu
lants, steroids.

Physical Examination
General Appearance: Pallor, diaphoresis, confusion, dehydration. Note
whether the patient looks ill, well, or malnourished.
Vital Signs: Supine and upright pulse and blood pressure (orthostatic
hypotension) (resting tachycardia indicates a 10-20% blood volume loss;
postural hypotension indicates a 20-30% blood loss), temperature.
Skin: Delayed capillary refill, pallor, petechiae. Hemorrhagic telangiectasia
(Osler-Weber-Rendu syndrome), abnormal pigmentation (Peutz-Jeghers
syndrome), jaundice, ecchymoses (coagulopathy), increased skin elasticity
(Ehlers-Danlos syndrome).
Eyes: Scleral pallor.

Mouth: Oropharyngeal lacerations, nasal bleeding, labial and buccal pigmenta

tion (Peutz-Jeghers syndrome).

Chest: Gynecomastia, breath sounds.
Heart: Systolic ejection murmur.
Abdomen: Dilated abdominal veins, bowel sounds, distention, tenderness,
masses, hepatic atrophy, splenomegaly.
Extremities: Edema, cold extremities.
Neurologic: Decreased mental status, gait.
Rectal: Masses, hemorrhoids. Polyps, fissures; stool color, occult blood testing.
Laboratory Evaluation: CBC, platelet count, reticulocyte count, international
normalized ratio (INR), partial thromboplastin time (PTT), bleeding time,
electrolytes, BUN, creatinine, glucose. Type and cross-match for 2-4 units of
packed RBC and transfuse as needed. ALT, AST, GGTP, glucose, electro
lytes. Esophagogastroduodenoscopy, colonoscopy, Meckel's scan, bleeding
scan.

Differential Diagnosis of Upper Gastrointestinal Bleeding

Age Common Less Common

Neonates (0-30 Swallowed maternal blood, Coagulopathy, vascular mal

days) gastritis, duodenitis formations, gastric/esoph
ageal duplication, leiomy
oma

Infants (30 days Gastritis, gastric ulcer, eso Esophageal varices, foreign
1 year) phagitis, duodenitis body, aortoesophageal
fistula

Children (1-12 Esophagitis, esophageal Leiomyoma, salicylates, vas

years) varices, gastritis, gastric cular malformation,
ulcer, duodenal ulcer, hematobilia, NSAIDs
Mallory-Weiss tear, na
sopharyngeal bleeding
60 Melena and Lower Gastrointestinal Bleeding

Age Common Less Common

Adolescents (12 Duodenal ulcer, esopha Thrombocytopenia, Dieula

years-adult) gitis, esophageal varices, foy's ulcer, hematobilia
gastritis, Mallory-Weiss
tear

Melena and Lower Gastrointestinal Bleeding

Chief Complaint: Anal bleeding
History of Present Illness: Duration, quantity, color of bleeding (gross blood,
streaks on stool, melena), recent hematocrit. Change in bowel habits, change
in stool caliber, abdominal pain, fever. Constipation, diarrhea, anorectal pain.
Epistaxis, anorexia, weight loss, malaise, vomiting.
Fecal mucus, excessive straining during defecation. Colitis, peptic ulcer,
hematemesis.
Past Medical History: Barium enema, colonoscopy, sigmoidoscopy, upper GI
series.
Medications: Anticoagulants, aspirin, NSAIDs.

Physical Examination
General Appearance: Dehydration, pallor. Note whether the patient looks ill,
well, or malnourished.
Vital Signs: BP (orthostatic hypotension), pulse, respiratory rate, temperature
(tachycardia).
Skin: Delayed capillary refill, pallor, jaundice. Spider angiomata, rashes,
purpura.
Eyes: Pale conjunctiva, icterus.
Mouth: Buccal mucosa discolorations or pigmentation (Henoch-Schnlein
purpura or Peutz-Jeghers syndrome).
Chest: Breath sounds.
Heart: Systolic ejection murmurs.
Abdomen: Masses, distention, tenderness, hernias, liver atrophy,
splenomegaly.
Genitourinary: Testicular atrophy.
Extremities: Cold, pale extremities.
Neurologic: Anxiety, confusion.
Rectal: Hemorrhoids, masses; fissures, polyps, ulcers. Gross or occult blood.
Laboratory Evaluation: CBC (anemia), liver function tests. Abdominal x-ray
series (thumbprinting, air fluid levels).

Differential Diagnosis of Lower Gastrointestinal Bleeding

Age Common Less Common

Neonates (0-30 Anorectal lesions, swal Vascular malformations,

days) lowed maternal blood, Hirschsprung's entero
milk allergy, necrotizing colitis, intestinal duplica
enterocolitis, midgut tion, coagulopathy
volvulus
 Melena and Lower Gastrointestinal Bleeding 61

Age Common Less Common

Infants (30 days Anorectal lesions, midgut Vascular malformations, in

1 year) volvulus, intussusception testinal duplication, acquir
(under 3 years) ed thrombocytopenia
Meckel's diverticulitis, infec
tious diarrhea, milk pro
tein allergy

Children (1-12 Juvenile polyps, Meckel's Henoch-Schnlein purpura,

years) diverticulitis, intussus hemolytic-uremic syn
ception (under 3 years), drome, vasculitis (SLE),
infectious diarrhea, anal inflammatory bowel dis
fissure, nodular lymphoid ease
hyperplasia

Adolescents (12 Inflammatory bowel dis Arteriovascular malformation,

years-adult) ease, polyps, hemor adenocarcinoma, Henoch-
rhoids, anal fissure, in Schnlein purpura,
fectious diarrhea Pseudomembranous colitis
62 Melena and Lower Gastrointestinal Bleeding
 Amenorrhea 63

Gynecologic Disorders

Amenorrhea
Chief Complaint: Missed period.
History of Present Illness: Date of last menstrual period. Primary amenorrhea
(absence of menses by age 16) or secondary amenorrhea (cessation of
menses after previously normal menstruation). Age of menarche, menstrual
regularity; age of breast development; sexual activity, possibility of pregnancy,
pregnancy testing. Symptoms of pregnancy (nausea, breast tenderness).
Lifestyle changes, dieting, excessive exercise, drugs (marijuana), psychologic
stress. Hot flushes (hypoestrogenism), galactorrhea (prolactinoma). Weight
loss or gain, headaches, vision changes.
Past Medical History: History of dilation and curettage, postpartum infection
(Ashermans syndrome), postpartum hemorrhage (Sheehan's syndrome);
prior pregnancies.
Medications: Contraceptives, tricyclic antidepressants, digoxin, marijuana,
chemotherapeutic agents.

Physical Examination
General Appearance: Secondary sexual characteristics, body habitus, obesity,
deep voice (hyperandrogenism). Note whether the patient looks ill or well.
Vital Signs: Pulse (bradycardia), temperature (hypothermia, hypothyroidism),
blood pressure, respirations.
Skin: Acne, hirsutism, temporal balding (hyperandrogenism, cool dry skin
(hypothyroidism).
Eyes: Visual field defects, bitemporal hemianopsia (pituitary adenoma).
Neck: Thyroid enlargement or nodules.
Chest: Galactorrhea, impaired breast development, breast atrophy.
Heart: Bradycardia (hypothyroidism).
Abdomen: Abdominal striae (Cushings syndrome).
Gyn: Pubic hair distribution, inguinal or labial masses, clitoromegaly, imperfo
rate hymen, vaginal septum, vaginal atrophy, uterine enlargement, ovarian
cysts or tumors.
Extremities: Tremor (hyperthyroidism).
Neurologic: Focal motor deficits.
Laboratory Evaluation: Pregnancy test, prolactin, TSH, free T4. Progesterone
challenge test.
64 Abnormal Vaginal Bleeding

Differential Diagnosis of Amenorrhea

Pregnancy Outflow tract-related

Hormonal contraception Imperforate hymen
Hypothalamic-related: Stress, athlet Transverse vaginal septum
ics, eating disorder, obesity, drugs Agenesis of the vagina, cervix, uterus
tumor Uterine synechiae
Pituitary-related: Hypopituitarism, Androgen excess
tumor, infiltration, infarction Polycystic ovarian syndrome
Ovarian-related: Dysgenesis, agen Adrenal tumor
esis, ovarian failure Adrenal hyperplasia
Ovarian tumor
Other endocrine causes
Thyroid disease
Cushing syndrome

Abnormal Vaginal Bleeding

Chief Complaint: Abnormal vaginal bleeding.
History of Present Illness: Last menstrual period, number of soaked pads per
day; menstrual regularity, age of menarche, duration and frequency of
menses; passing of clots; postcoital or intermenstrual bleeding; abdominal
pain, fever, lightheadedness; possibility of pregnancy, sexual activity,
hormonal contraception.
Psychologic stress, weight changes, exercise. Changes in hair or skin texture.
Past Medical History: Obstetrical history. Thyroid, renal, or hepatic disease;
coagulopathies, endometriosis, dental bleeding.
Family History: Coagulopathies, endocrine disorders.

Physical Examination
General Appearance: General body habitus, obesity. Note whether the patient
looks ill or well.
Vital Signs: Assess hemodynamic stability, tachycardia, hypotension,
orthostatic vitals; signs of shock.
Skin: Pallor, hirsutism, petechiae, skin texture; fine thinning hair
(hypothyroidism).
Neck: Thyroid enlargement.
Breasts: Masses, galactorrhea.
Chest: Breath sounds.
Heart: Murmurs.
Gyn: Cervical motion tenderness, adnexal tenderness, uterine size, cervical
lesions.
Laboratory Evaluation: CBC, platelets, beta-HCG, type and screen, cervix
culture for N. gonorrhoeae, Chlamydia test, von Willebrand's screen,
INR/PTT, bleeding time, pelvic ultrasound. Endometrial biopsy.
Differential Diagnosis of Abnormal Vaginal Bleeding: Chronic anovulation,
pelvic inflammatory disease, cervicitis, pregnancy (ectopic pregnancy,
spontaneous abortion, molar pregnancy). Hyperthyroidism, hypothyroidism,
adrenal disease, diabetes mellitus. Hyperprolactinemia, polycystic ovary
syndrome, oral contraceptives, medroxyprogesterone, anticoagulants,
NSAIDs. Cervical polyps, uterine myoma endometriosis, retained tampon,
trauma, Von Willebrand's disease.
 Pelvic Pain and Ectopic Pregnancy 65

Pelvic Pain and Ectopic Pregnancy

Chief Complaint: Pelvis pain.
History of Present Illness: Pelvic or abdominal pain (bilateral or unilateral),
positive pregnancy test, missed menstrual period, abnormal vaginal bleeding
(quantify). Date of last menstrual period. symptoms of pregnancy (breast
tenderness, bloating); menstrual interval, duration, age of menarche,
characteristics of pelvic pain; onset, duration, shoulder pain. Fever or vaginal
discharge.
Past Medical History: Surgical history, sexually transmitted diseases,
Chlamydia, gonorrhea, obstetrical history. Prior pelvic infection,
endometriosis, prior ectopic pregnancy, pelvic tumor, intrauterine device.
Medications: Oral contraceptives.

Physical Examination
General Appearance: Moderate or severe distress. Note whether the patient
looks ill or well.
Vital Signs: BP (orthostatic hypotension), pulse (tachycardia), respiratory rate
(tachypnea), temperature (low fever).
Skin: Cold skin, pallor, delayed capillary refill.
Chest: Breath sounds.
Heart: Murmurs.
Abdomen: Cullen's sign (periumbilical darkening, intraabdominal bleeding),
local then generalized tenderness, rebound tenderness.
Pelvic: Cervical discharge, cervical motion tenderness; Chadwick's sign
(cervical cyanosis, pregnancy); Hegar's sign (softening of uterine isthmus,
pregnancy); enlarged uterus, adnexal tenderness, cul-de-sac fullness.
Laboratory Evaluation: Quantitative beta-HCG, transvaginal ultrasound. Type
and hold, Rh type, CBC, UA with micro; GC, chlamydia culture. Laparoscopy.
Differential Diagnosis of Pelvic Pain
Pregnancy-Related Causes: Ectopic pregnancy, spontaneous abortion,
threatened abortion, incomplete abortion, intrauterine pregnancy with corpus
luteum bleeding.
Gynecologic Disorders: Pelvic inflammatory disease, endometriosis, ovarian
cyst hemorrhage or rupture, adnexal torsion, Mittelschmerz, primary
dysmenorrhea, tumor.
Nonreproductive Causes of Pelvic Pain
Gastrointestinal: Appendicitis, inflammatory bowel disease, mesenteric
adenitis, irritable bowel syndrome.
Urinary Tract: Urinary tract infection, renal calculus.
66 Pelvic Pain and Ectopic Pregnancy
 Headache 67

Neurologic Disorders

Headache
Chief Complaint: Headache
History of Present Illness: Quality of pain (dull, band-like, sharp, throbbing),
location (retro-orbital, temporal, suboccipital, bilateral or unilateral); age of
onset; time course of typical headache episode; rate of onset (gradual or
sudden); time of day, effect of supine posture. Increasing frequency.
Progression in severity. Does the headache interfere with normal activity or
cause the child to stop playing? Awakening from sleep; analgesic use. The
worst headache ever (subarachnoid hemorrhage).
Aura or Prodrome: Visual scotomata, blurred vision; nausea, vomiting, sensory
disturbances.
Associated Symptoms: Numbness, weakness, diplopia, photophobia, fever,
nasal discharge (sinusitis), neck stiffness (meningitis).
Aggravating or Relieving Factors: Relief by analgesics or sleep. Exacerbation
by light or sounds, straining, exercising, or changing position. Exacerbation
by foods (cheese), emotional upset, menses.
Past Medical History: Growth delay, development delay, allergies, past
illnesses. Head injuries, motion sickness. Anxiety or depression
Medications: Dosage, frequency of use, and effect of medications. Birth control
pills.
Family History: Migraine headaches in parents. Parental description of their
headaches.
Social History: School absences. Stressful events. Emotional problems at
home or in school. Cigarettes, alcohol, illegal drugs.
Review Systems: Changes in personality, memory, intellectual skills, vision,
hearing, strength, gait, or balance. Postural lightheadedness, weakness,
vertigo.

Physical Examination
General Appearance: Note whether the patient looks ill or well; interaction
with parents; sad or withdrawn?
Vital Signs: BP (hypertension), pulse, temperature (fever), respiratory rate.
Height, weight, head circumference; growth percentiles. Weight loss, lack of
linear growth.
Skin: Pallor, petechiae, bruises. Alopecia, rashes, and painless oral ulcers.
Caf au lait spots in the axillae or inguinal areas (neurofibromatosis). Facial
angiofibromas (adenoma sebaceum).
Head: Macrocephaly, cranial tenderness, temporal tenderness. Dilated scalp
veins, frontal bossing. Sinuses tenderness (sinusitis) to percussion, temporal
bruits (arteriovenous malformation).
Eyes: Downward deviation of the eyes ("sunset-ring" increased intracranial
pressure), extraocular movements, pupil reactivity; papilledema, visual field
deficits. Conjunctival injection, lacrimation (cluster headache).
Nose: Rhinorrhea (cluster headache).
Mouth: Tooth tenderness, gingivitis, pharyngeal erythema. Masseter muscle
spasm, restricted jaw opening (TMJ dysfunction).
Neck: Rigidity, neck muscle tenderness.
68 Seizures, Spells and Unusual Movements

Extremities: Absent femoral pulses, lower blood pressures in the legs

(coarctation of the aorta).
Neurologic Examination: Mental status, cranial nerve function, motor strength,
sensation, deep tendon reflexes. Disorientation, memory impairment,
extraocular muscle dysfunction, spasticity, hyperreflexia, clonus, Babinski
sign, ataxia, coordination.
Laboratory Evaluation: Electrolytes, ESR. CBC with differential, INR/PTT, MRI
scan.

Recurrent and Chronic Headaches: Temporal Patterns

Acute Recurrent Headache Chronic Progressive Headache

Migraine Central nervous system infection
Cluster headache Hydrocephalus
Acute sinusitis Pseudotumor cerebri
Hypertension Brain tumor
Intermittent hydrocephalus Vascular malformation
Vascular malformation Subdural hematoma
Subarachnoid hemorrhage Arnold-Chiari malformation
Carbon monoxide poisoning Lead poisoning
Chronic Nonprogressive
Headache
Tension-type headache
Chronic sinusitis
Ocular disorder
Dental abscess, temporomandibular
joint syndrome
Postlumbar puncture
Posttraumatic headache

Seizures, Spells and Unusual Movements

Chief Complaint: Seizure
History of Present Illness: Time of onset of seizure, duration, tonic-clonic
movements, description of seizure, frequency of episodes, loss of conscious
ness. Past seizures, noncompliance with anticonvulsant medication. Aura
before seizure (irritability, behavioral change, lethargy), incontinence of urine
or feces, post-ictal weakness or paralysis, injuries. Can the patient tell when
an episode will start? Warning signs, triggers for the spells (crying, anger,
boredom, anxiety, fever, trauma). Does he speak during the spell? Does the
child remember the spells afterward? What is the child like after the episode
(confused, alert)? Can the child describe what happens?
Past Medical History: Illnesses, hospitalizations, previous functioning,
rheumatic fever. Electroencephalograms, CT scans.
Medications: Antidepressants, stimulants, antiseizure medications.
Family History: Similar episodes in family, epilepsy, migraine, tics, tremors,
Tourette syndrome, sleep disturbance. Rheumatic fever, streptococcal in
fection liver disease, metabolic disorders.
 Apnea 69

Physical Examination
General Appearance: Post-ictal lethargy. Note whether the patient looks well
or ill. Observe the patient performing tasks (tying shoes, walking).
Vital Signs: Growth percentiles, BP (hypertension), pulse, respiratory rate,
temperature (hyperpyrexia).
Skin: Caf-au-lait spots, neurofibromas (Von Recklinghausen's disease).
Unilateral port-wine facial nevus (Sturge-Weber syndrome); facial
angiofibromas (adenoma sebaceum), hypopigmented ash leaf spots
(tuberous sclerosis).
HEENT: Head trauma, pupil reactivity and equality, extraocular movements;
papilledema, gum hyperplasia (phenytoin); tongue or buccal lacerations; neck
rigidity.
Chest: Rhonchi, wheeze (aspiration).

Heart: Rhythm, murmurs.

Extremities: Cyanosis, fractures, trauma.

Perianal: Incontinence of urine or feces.

Neuro: Dysarthria, visual field deficits, cranial nerve palsies, sensory deficits,

focal weakness (Todd's paralysis), Babinski's sign, developmental delay.

Laboratory Evaluation: Glucose, electrolytes, CBC, urine toxicology,
anticonvulsant levels, RPR/VDRL, EEG, MRI, lumbar puncture.

Differential Diagnosis of Seizures, Spells, and Unusual Movements

Epilepsy Choreoathetosis
Movement disorders Benign
Tics Familial
Myoclonic syndromes Paroxysmal
Sleep Sydenham chorea
Benign Huntington chorea
Hyperexplexia (exaggerated star Drugs
tle response) Behavioral/Psychiatric Disorders
Myoclonus-opsoclonus Pseudoseizures
Shuddering spells Automatisms
Dystonia Dyscontrol syndrome
Torsion Attention-deficit hyperactivity disor
Transient torticollis der
Sandifer syndrome Benign paroxysmal vertigo
Drugs Migraine
Dyskinesias Parasomnias
Metabolic/genetic Syncope
Reflex dystrophy Breathholding spells
Nocturnal
Physiologic

Apnea
Chief Complaint: Apnea.
History of Present Illness: Length of pause in respiration. Change in skin color
(cyanosis, pallor), hypotonia or hypertonia, resuscitative efforts (rescue
breaths, chest compressions). Stridor, wheezing, body position during the
event, state of consciousness before, during and after the event. Unusual
movements, incontinence, postictal confusional state. Regurgitation after
feedings. Vomitus in oral cavity during the event.
70 Apnea

Loud snoring, nocturnal enuresis, excessive daytime sleepiness; prior acute life
threatening events (ALTEs). Medications accessible to the child in the home.
Past Medical History: Abnormal growth, developmental delay, asthma.
Perinatal History: Prenatal exposure to infectious agents, maternal exposure
to opioids, difficulties during labor and delivery. Respiratory difficulties after
birth.
Immunizations: Pertussis.
Family History: Genetic or metabolic disorders, mental retardation, consang
uinity, fetal loss, neonatal death, sudden infant death syndrome, elicit drugs,
alcohol.
Social history: Physical abuse, previous involvement of the family with child
protective services.

Physical Examination

General Appearance: Septic appearance, level of consciousness.

Vital Signs: Length, weight, head circumference percentiles. Pulse, blood

pressure, respirations, temperature.

Skin: Cool, mottled extremities; delayed capillary refill, bruises, scars.
Nose: Nasal flaring, nasal secretions, mucosal erythema, obstruction, septal
deviation or polyps.
Mouth: Structure of the lips, tongue, palate; tonsillar lesions, masses.
Neck: Masses, enlarged lymph nodes, enlarged thyroid.
Chest: Increased respiratory effort, intercostal retractions, barrel chest. Irregular
respirations, periodic breathing, prolonged pauses in respiration, stridor.
Grunting, wheezing, crackles.
Heart: Rate and rhythm, S1, S2, murmurs. Preductal and postductal pulse delay
(right arm and leg pulse comparison).
Abdomen: Hepatomegaly, nephromegaly.
Extremities: Dependent edema, digital clubbing.
Neurologic: Mental status, muscle tone, strength. Cranial nerve function, gag
reflex.
Laboratory Evaluation: Glucose, electrolytes, BUN, creatinine, calcium,
magnesium, CBC, ECG, O2 saturation.
 Delirium, Coma and Confusion 71

Differential Diagnosis of Apnea

Central Nervous System Upper Airway (continued)

Dandy-Walker malformation Adenotonsillar hypertrophy
Arnold-Chiari malformation Epiglottitis
Seizures Post-extubation
Hypotonia, weakness Vocal cord paralysis
Ondine's curse Anaphylaxis
Metabolic/Toxic Lower Airway
Hypoglycemia Pneumonia
Hypocalcemia Bronchiolitis
Hyponatremia Pertussis
Acidosis Cardiovascular
Hypomagnesemia Structural disease
Opioids Dysrhythmia
Medium-chain acyl-CoA Gastrointestinal
dehydrogenase deficiency Gastroesophageal reflux
Upper Airway Miscellaneous
Craniofacial syndromes Sepsis
Laryngomalacia Meningitis
Rhinitis Munchausen syndrome by proxy
Choanal stenosis/atresia
Croup

Delirium, Coma and Confusion

Chief Complaint: Confusion.
History of Present Illness: Level of consciousness, obtundation (awake but not
alert), stupor (unconscious but awakable with vigorous stimulation), coma
(cannot be awakened). Confusion, impaired concentration, agitation. Fever,
headache. Activity and symptoms prior to onset.
Past Medical History: Suicide attempts or depression, epilepsy (post-ictal
state).
Medications: Insulin, narcotics, drugs, anticholinergics.

Physical Examination
General Appearance: Incoherent speech, lethargy, somnolence. Dehydration,
septic appearance. Note whether the patient looks ill or well.
Vital Signs: BP (hypertensive encephalopathy), pulse, temperature (fever),
respiratory rate.
Skin: Cyanosis, jaundice, delayed capillary refill, petechia, splinter hemor
rhages; injection site fat atrophy (diabetes).
Head: Skull tenderness, lacerations, ptosis, facial weakness. Battle's sign
(ecchymosis over mastoid process), raccoon sign (periorbital ecchymosis,
skull fracture), hemotympanum (basal skull fracture).
Eyes: Pupil size and reactivity, extraocular movements, papilledema.
Mouth: Tongue or cheek lacerations; atrophic tongue, glossitis (B12 deficiency).
Neck: Neck rigidity, masses.
Chest: Breathing pattern (Cheyne-Stokes hyperventilation), crackles, wheezes.
Heart: Rhythm, murmurs, gallops.
Abdomen: Hepatomegaly, splenomegaly, masses.
Neuro: Strength, cranial nerves 2-12, mini-mental status exam; orientation to
person, place, time, recent events; Babinski's sign, primitive reflexes (snout,
72 Delirium, Coma and Confusion

suck, glabella, palmomental grasp).

Laboratory Evaluation: Glucose, electrolytes, BUN, creatinine, O2 saturation,
liver function tests. CT/MRI, urine toxicology screen.
Differential Diagnosis of Delirium: Hypoxia, meningitis, encephalitis, systemic
infection, electrolyte imbalance, hyperglycemia, hypoglycemia (insulin
overdose), drug intoxication, stroke, intracranial hemorrhage, seizure;
dehydration, head trauma, uremia, vitamin B12 deficiency, ketoacidosis,
factitious coma.
 Polyuria, Enuresis and Urinary Frequency 73

Renal and Endocrinologic Disorders

Polyuria, Enuresis and Urinary Frequency

Chief Complaint: Excessive urination.
History of Present Illness: Time of onset of excessive urination. Constant
daytime thirst or waking at night to drink. Poor urinary stream, persistent
dribbling of urine; straining to urinate. Excessive fluid intake, dysuria,
recurrent urinary tract infections; urgency, daytime and nighttime enuresis,
fever. Gait disturbances, history of lumbar puncture, spinal cord injury. Lower
extremity weakness; back pain, leg pain. Use of harsh soaps for bathing.
Feeding schedule, overfeeding, growth pattern, dehydration. Vomiting,
constipation. Abdominal and perineal pain, constipation, encopresis
Past Medical History: Urinary tract infections, diabetes, renal disease.

Social History: History of foreign body insertion or sexual abuse.

Family History: Family members with polydipsia, polyuria; early infant deaths,

infants with poor growth or dehydration; genitourinary disorders. Parental age

of toilet training.

Physical Examination

General Appearance: Signs of dehydration, septic appearance.

Vital Signs: Blood pressure (hypertension), pulse (tachycardia), temperature,

respirations. Growth percentiles, growth failure.

Chest: Breath sounds.
Heart: Murmurs, third heart sound.
Abdomen: Masses, palpable bladder. Perineal excoriation; lumbosacral midline
defects, sacral hairy patch, sacral hyperpigmentation, sacral dimple or sinus
tract, hemangiomas.
Rectal Examination: Rectal sphincter laxity, anal reflex (sacral nerve function).
Extremities: Asymmetric gluteal cleft, gluteal lipoma, gluteal wasting.
Neurologic Examination: Deep tendon reflexes, muscle strength in the legs
and feet. Perineal sensation, gait disturbance.

Differential Diagnosis of Polyuria

Water Diuresis
Primary polydipsia
Diabetes insipidus
Obstruction by posterior urethral valves, uteropelvic junction obstruction, ectopic
ureter, nephrolithiasis
Renal infarction secondary to sickle-cell disease
Chronic pyelonephritis
Solute Diuresis: Glucose, urea, mannitol, sodium chloride, mineralocorticoid
deficiency or excess, alkali ingestion
74 Hematuria

Differential Diagnosis of Enuresis and Urinary Frequency

Infection Diabetes insipidus

Uteropelvic junction obstruction Wilms tumor
Obstructive ectopic ureter Neuroblastoma
Posterior urethral valves Pelvic tumors
Nephrolithiasis Fecal impaction
Diabetes mellitus

Hematuria
Chief Complaint: Blood in urine.
History of Present Illness: Color of urine, duration and timing of hematuria.
Frequency, dysuria, suprapubic pain, flank pain (renal colic), abdominal or
perineal pain, fever, menstruation.
Foley catheterization, stone passage, tissue passage in urine, joint pain.
Strenuous exercise, dehydration, recent trauma. Rashes, arthritis (systemic
lupus erythematosus, Henoch-Schnlein purpura). Bloody diarrhea
(hemolytic-uremic syndrome), hepatitis B or C exposure.
Causes of Red Urine: Pyridium, phenytoin, ibuprofen, cascara laxatives,
rifampin, berries, flava beans, food coloring, rhubarb, beets, hemoglobinuria,
myoglobinuria.
Past Medical History: Recent sore throat (group A streptococcus), streptococ
cal skin infection (glomerulonephritis). Recent or recurrent upper respiratory
illness (adenovirus).
Medications Associated with Hematuria: Warfarin, aspirin, ibuprofen,
naproxen, phenobarbital, phenytoin, cyclophosphamide.
Perinatal History: Birth asphyxia, umbilical catheterization.
Family History: Hematuria, renal disease, sickle cell anemia, bleeding
disorders, hemophilia, deafness (Alport's syndrome), hypertension.
Social History: Occupational exposure to toxins.

Physical Examination
General Appearance: Signs of dehydration. Note whether the patient looks ill
or well.
Vital Signs: Hypertension (acute renal failure, acute glomerulonephritis), fever,
respiratory rate, pulse.
Skin: Pallor, malar rash, discoid rash (systemic lupus erythematosus);
ecchymoses, petechiae (Henoch-Schnlein purpura).
Face: Periorbital edema (nephritis, nephrotic syndrome).
Eyes: Lens dislocation, dot-and-fleck retinopathy (Alport's syndrome).
Throat: Pharyngitis.
Chest: Breath sounds.
Heart: Rhythm, murmurs, gallops.
Abdomen: Masses, nephromegaly (Wilms' tumor, polycystic kidney disease,
hydronephrosis), abdominal bruits, suprapubic tenderness.
Back: Costovertebral angle tenderness (renal calculus, pyelonephritis).
Genitourinary: Discharge, foreign body, trauma, meatal stenosis.
Extremities: Peripheral edema (nephrotic syndrome), joint swelling, joint
tenderness (rheumatic fever), unequal peripheral pulses (aortic coarctation).
Laboratory Evaluation: Urinalysis with microscopic, urine culture; creatinine,
 Proteinuria 75

BUN, CBC; sickle cell screen; urine calcium-to-creatinine ratio, INR/PTT.

Urinalysis of first-degree relatives (Alport's syndrome or benign familial
hematuria), renal ultrasonography.
Specific Laboratory Evaluation: Complement levels, anti-streptolysin-O and
anti-DNAse B (poststreptococcal glomerulonephritis), antinuclear antibody,
audiogram (Alport's syndrome), antiglomerular basement membrane
antibodies (Goodpasture's syndrome), antineutrophil cytoplasmic antibodies,
purified protein derivative (PPD).
Advanced Laboratory Evaluation: Voiding cystourethrogram, intravenous
pyelography, CT scan, MRI scan, renal scan, renal biopsy.

Differential Diagnosis of Microscopic Hematuria

Glomerular Diseases

Benign familial or sporadic hematuria Membranoproliferative glomerulo

(thin membrane nephropathy) nephritis
Acute postinfectious glomerulonephritis Systemic lupus erythematosus
Hemolytic-uremic syndrome Henoch-Schnlein nephritis
IgA nephropathy (Berger's disease) Polyarteritis
Alport's syndrome (familial nephritis) Hepatitis-associated glomerulonephritis
Focal segmental glomerulonephritis

Nonglomerular Diseases

Strenuous exercise Leukemia

Dehydration Coagulopathy
Fever Anatomical abnormalities
Menstruation Hydronephrosis
Foreign body in urethra or bladder Ureteropelvic junction obstruction
Urinary tract infection: bacterial, Cystic kidneys
adenovirus, tuberculosis Polycystic kidney disease
Hypercalciuria Medullary cystic disease
Urolithiasis Vascular malformations
Sickle cell trait or disease Arteriovenous fistula
Trauma Renal vein thrombosis
Drugs and toxins Nutcracker syndrome
Masturbation Papillary necrosis
Tumors Parenchymal infarction
Wilms' tumor Munchausen syndrome-by-proxy
Tuberous sclerosis
Renal or bladder cancer

Proteinuria
Chief Complaint: Proteinuria.
History of Present Illness: Protein of 1+ (30 mg/dL) on a urine dipstick. Protein
above 4 mg/m2/hour in a timed 12- to 24-hour urine collection (significant
proteinuria). Prior proteinuria, hypertension, edema; short stature, hearing
deficits.
Past Medical History: Renal disease, heart disease, arthralgias.
Medications: Chemotherapy agents.
Family History: Renal disease, deafness.
76 Proteinuria

Physical Examination

General Appearance: Signs of dehydration. Note whether the patient looks ill

or well.
Vital Signs: Temperature (fever).
Ears: Dysmorphic pinnas.
Skin: Caf-au-lait spots, hypopigmented macules, rash.
Extremities: Joint tenderness, joint swelling.
Laboratory Evaluation: Urinalysis for spot protein/creatinine ratio. Recumbent
and ambulating urinalyses. CBC, electrolytes, BUN, creatinine, total protein,
albumin, cholesterol, antistreptolysin-O titer (ASO), antinuclear antibody,
complement levels. Renal ultrasound, voiding cystourethrogram.

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-Schnlein purpura
Systemic lupus erythematosus
Hereditary nephritis

Tubulointerstitial Disease
Reflux nephropathy Lowe syndrome
Interstitial nephritis Tubular toxins
Hypokalemic nephropathy Drugs (eg, aminoglycosides and
Cystinosis penicillins)
Fanconi's syndrome Heavy metals
Tyrosinemia Ischemic tubular injury
 Swelling and Edema 77

Swelling and Edema

Chief Complaint: Swollen ankles.
History of Present Illness: Duration of edema; distribution (localized or
generalized); intermittent or persistent swelling, pain, redness. Renal disease;
shortness of breath, malnutrition, chronic diarrhea (protein losing
enteropathy), allergies. Periorbital edema, ankle edema, weight gain.
Poor exercise tolerance, fatigue, inability to keep up with other children. Poor
feeding, fussiness, restlessness. Bloody urine (smoky or red), decreased
urine output, jaundice. Poor protein intake (Kwashiorkor), dietary history.
Past Medical History: Menstrual cycle, sexual activity, premenstrual bloating,
pregnancy, rash.
Medications: Over-the-counter drugs, diuretics, oral contraceptives, anti
hypertensives, estrogen, lithium.
Allergies: Allergic reactions to foods (cow's milk).
Family History: Lupus erythematosus, cystic fibrosis, renal disease, Alport syn
drome, hereditary angioedema, deafness.
Social History: Exposure to toxins, illicit drugs, alcohol, chemicals.

Physical Examination
General Appearance: Respiratory distress, pallor. Note whether the patient
looks ill or well.
Vitals: BP (upright and supine), pulse (tachycardia), temperature, respiratory
rate (tachypnea). Growth percentiles, poor weight gain. Decreased urine
output.
Skin: Xanthomata, spider angiomata, cyanosis. Rash, insect bite puncta,
erythema.
HEENT: Periorbital edema. Conjunctival injection, scleral icterus, nasal polyps,
sinus tenderness, pharyngitis.
Chest: Breath sounds, crackles, dullness to percussion.
Heart: Displacement of point of maximal impulse; silent precordium, S3 gallop,
friction rub, murmur.
Abdomen: Distention, bruits, hepatomegaly, splenomegaly, shifting dullness.
Extremities: Pitting or non-pitting edema (graded 1 to 4+), erythema, pulses,
clubbing.
Laboratory Evaluation: Electrolytes, liver function tests, triglycerides, albumin,
CBC, chest x-ray, urine protein.
78 Diabetic Ketoacidosis

Differential Diagnosis of Edema

Increased Hydrostatic Pressure Decreased Oncotic Pressure

Congestive heart failure (Hypoproteinemia)
Pericarditis Nephrotic syndrome
Superior vena cava syndrome Liver disease (alpha -antitrypsin defi
Arteriovenous fistula 1
ciency, infectious hepatitis)
Venous thrombosis Cirrhosis
Lymphatic obstruction by tumors Galactosemia
Syndrome of inappropriate ADH secre Kwashiorkor
tion Marasmus
Steroids Cystic fibrosis
Excessive Iatrogenic fluid administration Inflammatory bowel disease
Protein-losing enteropathy (cow's milk
Increased Capillary Permeability allergy)
Rocky Mountain spotted fever Intestinal lymphangiectasia
Stevens-Johnson syndrome Celiac disease
Bezoar
Infection (Giardia sp.)
Pancreatic pseudocyst
Severe anemia
Zinc deficiency

Diabetic Ketoacidosis
Chief Complaint: Malaise.
History of Present Illness: Initial glucose level, ketones, anion gap. Duration
of polyuria, polyphagia, polydipsia, lethargy, dyspnea, weight loss; noncompli
ance with insulin; blurred vision, infection, dehydration, abdominal pain
(appendicitis). Cough, fever, chills, ear pain (otitis media), dysuria (urinary
tract infection).
Factors that May Precipitate Diabetic Ketoacidosis. New onset of diabetes,
noncompliance with insulin, infection, pancreatitis, myocardial infarction,
stress, trauma, pregnancy.
Past Medical History: Age of onset of diabetes; renal disease, infections,
hospitalization.

Physical Examination
General Appearance: Somnolence, Kussmaul respirations (deep sighing
breathing), dehydration. Note whether the patient looks toxic or well.
Vital Signs: BP (hypotension), pulse (tachycardia), temperature (fever,
hypothermia), respiratory rate (tachypnea).
Skin: Decreased skin turgor, delayed capillary refill, intertriginous candidiasis,
erythrasma, localized fat atrophy (insulin injections).
Eyes: Diabetic retinopathy (neovascularization, hemorrhages), decreased visual
acuity.
Mouth: Acetone breath odor (musty, apple odor), dry mucous membranes
(dehydration).
Ears: Tympanic membrane erythema (otitis media).
Chest: Rales, rhonchi (pneumonia).
Heart: Murmurs.
Abdomen: Hypoactive bowel sounds (ileus), right lower quadrant tenderness
 Diabetic Ketoacidosis 79

(appendicitis), suprapubic tenderness (cystitis), costovertebral angle

tenderness (pyelonephritis).
Extremities: Abscesses, cellulitis.
Neurologic: Confusion, hyporeflexia.
Laboratory Evaluation: Glucose, sodium, potassium, bicarbonate, chloride,
BUN, creatinine, anion gap, phosphate, CBC, serum ketones; UA
(proteinuria, ketones). Chest x-ray.
Differential Diagnosis
Ketosis-causing Conditions: Alcoholic ketoacidosis or starvation.
Acidosis-causing Conditions
Increased Anion Gap Acidoses: Lactic acidosis, uremia, salicylate or
methanol poisoning.
Non-Anion Gap Acidoses: Diarrhea, renal tubular acidosis.
Diagnostic Criteria for DKA. Glucose 250, pH <7.3, bicarbonate <15, ketone
positive >1:2 dilutions.
80 Diabetic Ketoacidosis
 Rash 81

Dermatologic, Hematologic and

Rheumatologic Disorders

Rash
Chief Complaint: Rash.
History of Present Illness: Time of rash onset, location, pattern of spread
(chest to extremities). Location where the rash first appeared; what it
resembled; what symptoms were associated with it; what treatments have
been tried. Fever, malaise, headache; conjunctivitis, coryza, cough. Exposure
to persons with rash, prior history of chicken pox. Sore throat, joint pain,
abdominal pain. Exposure to allergens or irritants. Sun exposure, cold,
psychologic stress.
Past Medical History: Prior rashes, asthma, allergic rhinitis, urticaria, eczema,
diabetes, hospitalizations, surgery.
Medications: Prescription and nonprescription, drug reactions.
Family History: Similar problems among family members.
Immunizations: Vaccination status, measles, mumps, rubella.
Social History: Drugs, alcohol, home situation.

Physical Examination

General Appearance: Respiratory distress, toxic appearance.

Vital Signs: Temperature, pulse, blood pressure, respirations.

Skin: Complete skin examination, including the nails and mucous membranes.

Color or surface changes, texture changes, warmth. Distribution of skin lesions

(face, trunk, extremities), shape of the lesions, arrangement of several lesions

(annular, serpiginous, dermatomal); color of the lesions, dominant hue and
the color pattern, surface characteristics (scaly, verrucous), erythema,
papules, induration, flat, macules, vesicles, ulceration, margin character,
lichenification, excoriations, crusting.
Eyes: Conjunctival erythema.

Ears: Tympanic membranes.

Mouth: Soft palate macules; buccal mucosa lesions.

Throat: Pharyngeal erythema.

Lymph Nodes: Cervical, axillary, inguinal lymphadenopathy.

Chest: Rhonchi, crackles , wheezing.

Heart: Murmurs.

Abdomen: Tenderness, masses, hepatosplenomegaly.

Extremities: Rash on hands, feet, palms, soles; joint swelling, joint tenderness.

Differential Diagnosis: Varicella, rubella, measles, scarlet fever, eczema,

dermatitis, rocky mountain spotted fever, drug eruption, Kawasakis disease.

Laboratory Diagnosis: Virus isolation or antigen detection (blood,
nasopharynx, conjunctiva, urine). Acute and convalescent antibody titers.
82 Bruising and Bleeding

Bruising and Bleeding

Chief Complaint: Bruising
History of Present Illness: Time of onset of bruising; trauma, spontaneous
ecchymoses, petechiae; bleeding gums, bleeding into joints, epistaxis,
hematemesis, melena. Bone pain, joint pain, abdominal pain. Is the bleeding
lifelong or of recent onset? Hematuria, extensive bleeding with trauma.
Weight loss, fever, pallor, jaundice, recurring infections.
Past Medical History: Oozing from the umbilical stump after birth, bleeding at
injection sites. Prolonged bleeding after minor surgery (circumcision) or after
loss of primary teeth.
Family History: Bleeding disorders, anticoagulant use, availability of
rodenticides or antiplatelet drugs (eg, aspirin or other nonsteroidals) in the
home. Child abuse.
Social History: History of child abuse, family stress.

Physical Examination
General Appearance: Ill-appearance.
Vital Signs: Tachypnea, tachycardia, fever, blood pressure (orthostatic
changes), cachexia.
Skin: Appearance and distribution of petechiae (color, size, shape, diffuse,
symmetrical), ecchymotic patterns (eg, belt buckle shape, doubled-over
phone cord); folliculitis (neutropenia). Hyperextensible skin (Ehlers-Danlos
syndrome). Partial albinism (Hermansky-Pudlak syndrome). Palpable purpura
on legs (vasculitis, Henoch-Schnlein purpura).
Lymph Nodes: Cervical or axillary lymphadenopathy
Eyes: Conjunctival pallor, erythema.
Nose: Epistaxis, nasal eschar.
Mouth: Gingivitis, mucous membrane bleeding, oozing from gums, oral
petechiae.
Chest: Wheezing, rhonchi.
Heart: Murmurs.
Abdomen: Hepatomegaly, splenomegaly, nephromegaly.
Rectal: Stool occult blood.
Extremities: Muscle hematomas; anomalies of the radius bone
(thrombocytopenia absent radius [TAR] syndrome). Bone tenderness, joint
tenderness, hemarthroses; hypermobile joints (Ehlers-Danlos syndrome.
Past Testing: X-ray studies, endoscopy.
 Kawasaki Disease 83

Differential Diagnosis of Bruising and Bleeding

Hemolytic uremic syndrome Takayasu arteritis

Thrombotic thrombocytopenic purpura Polyarteritis nodosa
Uremia Kawasaki syndrome
Paraproteinemia Henoch-Schnlein purpura
Myelodysplastic syndrome Leukocytoclastic ("hypersensitivity)
Phenytoin, valproic acid, quinidine, hep vasculitis
arin Wegener granulomatosis
Afibrinogenemia/dysfibrinogenemia Churg-Strauss syndrome
Clotting factor deficiencies (hemophilia Essential cryoglobulinemia
A, B, Christmas disease) Systemic lupus erythematosus
Von Willebrand disease Juvenile rheumatoid arthritis
Vitamin K deficiency Mixed connective tissue disease
Hemorrhagic disease of the newborn Dermatomyositis, scleroderma
Trauma Bacterial or viral infection, spirochetal
Vasculitis infection, rickettsial infection
Giant cell (temporal) arteritis Malignancy

Kawasaki Disease
Chief Complaint: Fever.
History of Present Illness: Fever of unknown cause, lasting 5 days or more;
irritability, chest pain. Eye redness. Redness, dryness or fissuring of lips,
strawberry tongue. Diarrhea, vomiting, abdominal pain, arthritis/arthralgias.
Absence of cough, rhinorrhea, vomiting.

Physical Examination
General Appearance: Ill appearance, irritable.
Vital Signs: Pulse (tachycardia), blood pressure (hypotension), respirations,
temperature (fever).
Skin: Diffuse polymorphous rash (macules, bullae, erythematous exanthem) of
the trunk; morbilliform or scarlatiniform rash.
Eyes: Bilateral conjunctival congestion (dilated blood vessels without purulent
discharge), erythema, conjunctival suffusion, uveitis.
Mouth: Erythema of lips, fissures of lips; swollen, erythematous tongue. Diffuse
injection of oral and pharyngeal mucosa.
Lymph Nodes: Cervical lymphadenopathy.
Chest: Breath sounds.
Heart: Murmur, gallop rhythm, distant heart sounds.
Abdomen: Tenderness, hepatomegaly, splenomegaly.
Extremities: Edema, erythema of the hands and feet; warm, red, swollen hands
and feet. Joint swelling, joint tenderness. Desquamation of the fingers or toes,
usually around nails and spreading over palms and soles (late).
Laboratory Evaluation: CBC with differential, platelet count, electrolytes, liver
function tests, ESR, CRP, throat culture, antistreptolysin-O titer, blood
cultures.
Urinalysis: Proteinuria, increase of leukocytes in urine sediment (sterile pyuria)
ECG: Prolonged PR, QT intervals, abnormal Q wave, low voltage, ST-T
changes, arrhythmias.
CXR: Cardiomegaly
Echocardiography: Pericardial effusion, coronary aneurysm, myocardial
84 Kawasaki Disease

infarction.
Differential Diagnosis: Scarlet fever (no hand, foot, or conjunctival involve
ment), Stevens-Johnson syndrome (mouth sores, cutaneous bullae, crusts),
measles (rash occurs after fever peaks and begins on head/scalp), toxic
shock syndrome, viral syndrome, drug reaction.
 Failure to Thrive 85

Behavioral Disorders and Trauma

Failure to Thrive
Chief Complaint: Inadequate growth.
History of Present Illness: Weight loss, change in appetite, vomiting,
abdominal pain, diarrhea, fever. Date when the parents became concerned
about the problem, previous hospitalizations. Polyuria, polydipsia; jaundice;
cough.
Nutritional History: Appropriate caloric intake, 24-hour diet recall; dietary
calendar; types and amounts of food offered. Proper formula preparation.
Parental dietary restrictions (low fat).
Past Medical History: Excessive crying, feeding problems. Poor suck and
swallow, fatigue during feeding. Unexplained injuries.
Developmental History: Developmental delay, loss of developmental
milestones.
Perinatal History: Delayed intrauterine growth, maternal illness, medications
or drugs (tobacco, alcohol). Birth weight, perinatal jaundice, feeding
difficulties.
Family History: Short stature, parental heights and the ages at which the
parents achieved puberty. Siblings with poor growth. Deaths in siblings or
relatives during early childhood (metabolic or immunologic disorders).
Social History: Parental HIV-risk behavior (bisexual exposure, intravenous
drug abuse, blood transfusions). Parental histories of neglect or abuse in
childhood; current stress within the family, financial difficulties, marital discord.

Historical Findings in Failure to Thrive

Poor Caloric Intake Diarrhea, dysentery, fever

Breast-feeding mismanagement Inflammatory bowel disease
Lactation failure Radiation, chemotherapy
Improper formula preparation Hypogeusia, anorexia
Maternal stress, poor diet, illness Recurrent infections
Eating disorders Rash, arthritis, weakness
Aberrant parental nutritional beliefs Jaundice
Food faddism Polyuria, polydipsia, polyphagia
Diaphoresis or fatigue while eating Irritability, constipation
Poor suck, swallow Mental retardation, swallowing difficul
Vomiting, hyperkinesis ties
Bilious vomiting Intrauterine growth delay
Recurrent pneumonias, steatorrhea

Physical Examination
General Appearance: Cachexia, dehydration. Note whether the patient looks
ill, well, or malnourished. Observation of parent-child interaction; affection,
warmth. Passive or withdrawn behavior. Decreased vocalization, expression
less facies; increased hand and finger activities (thumb sucking), infantile
posture; motor inactivity (congenital encephalopathy or rubella).
Developmental Examination: Delayed abilities for age on developmental
screening test.
Vital Signs: Pulse (bradycardia), BP, respiratory rate, temperature (hypother-
86 Failure to Thrive

mia). Weight, length, and head circumference; short stature, growth

percentiles.
Skin: Pallor, jaundice, skin laxity, rash.
Lymph Nodes: Cervical or supraclavicular lymphadenopathy.
Head: Temporal wasting, congenital malformations.
Eyes: Cataracts (rubella), icterus, dry conjunctiva.
Mouth: Dental erosions, oropharyngeal lesions, cheilosis (cobalamin defi
ciency), glossitis (Pellagra).
Neck: Thyromegaly.
Chest: Barrel shaped chest, rhonchi.
Heart: Displaced point of maximal impulse, patent ductus arteriosus murmur,
aortic stenosis murmur.
Abdomen: Protuberant abdomen, decreased bowel sounds (malabsorption,
obstructive uropathy), tenderness. Periumbilical adenopathy. Masses (pyloric
stenosis or obstructive uropathy), hepatomegaly (galactosemia), spleno
megaly.
Extremities: Edema, muscle wasting.
Neuro: Decreased peripheral sensation.
Rectal: Occult blood, masses.
Genitalia: Hypospadias (obstructive uropathy).

Physical Examination Findings in Growth Deficiency

Micrognathia, cleft lip and palate Short stature

Poor suck, swallow Cachexia, mass
Hyperkinesis Rash, joint erythema, tenderness,
Bulging fontanelle, papilledema weakness
Nystagmus, ataxia Jaundice, hepatomegaly
Abdominal distension Ambiguous genitalia, mas
Fever culinization
Clubbing Irritability
Perianal skin tags

Laboratory Evaluation: CBC, electrolytes, protein, albumin, transferrin, thyroid

studies, liver function tests.

Differential Diagnosis of Failure to Thrive

Poor Caloric Intake

Breast-feeding mismanagement
Lactation failure
Maternal stress, poor diet, illness
Eating disorders (older children)
Aberrant parental nutritional beliefs
Food faddism
Improper formula preparation
Micrognathia, cleft lip, cleft palate
Cardiopulmonary disease
Hypotonia, CNS disease
Diencephalic syndrome
 Developmental Delay 87

Poor Caloric Retention

Increased intracranial pressure
Labyrinthine disorders
Esophageal obstruction, gastroesophageal reflux, preampullary obstruction
Intestinal obstruction, volvulus, 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 History: Age when parents first became concerned about
delayed development. Rate and pattern of acquisition of skills; developmental
regressions. Parents' description of the child's current skills. 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, responsiveness). Developmental
quotient (DQ): Developmental age divided by the child's chronologic age x
100. Vision and hearing deficits.
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: Caf 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
 Attempted Suicide and Drug Overdose 91

(1) To person: Verbal children should know their names.

(2) To place: Young children should know whether they are away or
at home.
(3) To time: A sense of time is formed by age 8 or 9. Young children
can tell whether it is day or night.
D. Central Nervous System Function: Soft signs (persistent
neurodevelopmental immaturities):
(1) Gross Motor Coordination Deficiency: Impaired gait.
(2) Fine Motor Coordination: Copies a circle at age 2 to 3, cross at
age 3 to 4, square at age 5, rhomboid at age 7.
a. Laterality: Right and left discrimination by age 5.
b. Rapid Alternating Movements: Hopping on one foot by age 7.
c. Attention Span: Distractibility, hyperactivity.
E. Reading or Writing Difficulties: Dyslexia, dysgraphia.
F. Speech and Language Difficulties: Autism, mental retardation,
deprivation, regression.
G. Intelligence: Vocabulary, level of comprehension, ability to identify body
parts by age 5, drawing ability, mathematical ability.
H. Memory: Children can count five digits forward and two backwards.
I. Thinking Process: Logical and coherent thoughts, hallucinations,
suicidal ideation, homicidal ideation, phobias, obsessions, delusions.
J. Fantasies and Inferred Conflicts: Dreams, naming three wishes,
drawing, spontaneous play.
K. Affect: Anxiety, anger, depression, apathy.
L. Defense Organization: Denial, projection, introversion, extroversion.
M. Judgment and Insight: The childs opinion of the cause of the problem.
How upset is the child about the problem?
N. Adaptive Capacities: Problem-solving ability, resiliency.

Attempted Suicide and Drug Overdose

History of Present Illness: Time suicide was attempted and method. Quantity
of pills; motive for attempt. Alcohol intake; where was substance obtained.
Precipitating factor for suicide attempt (death, divorce, humiliating event);
further desire to commit suicide. Is there a definite plan? Was the action
impulsive or planned?
Feelings of sadness, guilt, hopelessness, helplessness. Reasons that the
patient has to wish to go on living. 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.
Medications: Antidepressants.
Family History: Depression, suicide, psychiatric disease, marital conflict, family
support.
Social History: Personal or family history of emotional, physical, or sexual
abuse; alcohol or drug abuse, sources of emotional stress. Availability of
other dangerous medications or weapons.

Physical Examination
General Appearance: Level of consciousness, delirium; presence of potentially
dangerous objects (belts, shoe laces).
Vital Signs: BP (hypotension), pulse (bradycardia), temperature, respiratory
92 Toxicological Emergencies

rate.
HEENT: Signs of trauma, ecchymoses; pupil size and reactivity, mydriasis,
nystagmus.
Chest: Abnormal respiratory patterns, rhonchi (aspiration).
Heart: Arrhythmias, murmurs.
Abdomen: Decreased bowel sounds, tenderness.
Extremities: Wounds, ecchymoses, fractures.
Neurologic: Mental status exam; tremor, clonus, hyperactive reflexes.
Laboratory Evaluation: Electrolytes, BUN, creatinine, glucose. Alcohol,
acetaminophen levels; chest X-ray, urine toxicology screen.

Toxicological Emergencies
History of Present Illness: Substance ingested, time of ingestion, quantity
ingested (number of pills/volume of liquid). Was this a suicide attempt or
gesture? Vomiting, lethargy, seizures, altered consciousness.
Past Medical History: Previous poisonings; heart, lung, kidney, gastrointesti
nal, or central nervous system disease.

Physical Examination
Vital Signs: Tachycardia (stimulants, anticholinergics), hypoventilation
(narcotics, depressants), fever (anticholinergics, aspirin, stimulants).
Skin: Dry mucosa (anticholinergic); very moist skin (cholinergic or
sympathomimetic).
Mouth:

Breath: Alcohol, hydrocarbon, cyanide odor.

Eyes: Meiosis, mydriasis, nystagmus (phenytoin or phencyclidine).

Chest: Breath sounds.

Cardiac: Bradycardia (beta-blocker, cholinergic, calcium channel blocker).

Abdomen: Decreased bowel sounds (anticholinergic or narcotic).

Neurological: Gait, reflexes, mental status, stimulation, sedation.

Laboratory Evaluation: Glucose (low in alcohols, oral hypoglycemics, aspirin,

beta-blockers, insulin; high in iron, late aspirin), hypokalemia (lithium). Arterial

blood gases. Liver function tests, WBC, toxicology screen of urine and serum.
Methemoglobin test of blood. Ferric chloride urine test for aspirin.
Kidney, Ureter and Bladder (KUB) X-ray: Radiopaque pill fragments are seen
with calcium, chloral hydrate, heavy metals (lead), iron, Pepto Bismol,
phenothiazines, enteric-coated pills.
ECG: Prolonged QTc or widened QRS (tricyclic antidepressants).

Toxicologic Syndromes

Toxin Clinical Findings

Iron Diarrhea, bloody stools, metabolic acidosis,

hematemesis, coma, abdominal pain, leuko
cytosis, hyperglycemia

Opioids Coma, respiratory depression, miosis, track

marks, bradycardia, decreased bowel sounds
 Trauma 93

Organophosphates Miosis, cramps, salivation, urination, broncho

rrhea, lacrimation, defecation, bradycardia

Salicylates Hyperventilation, fever, diaphoresis, tinnitus,

hypo- or hyperglycemia, hematemesis, altered
mental status, metabolic acidosis, respiratory
alkalosis

Phencyclidine Muscle twitching, rigidity, agitation, nystagmus,

(PCP) hypertension, tachycardia, psychosis, blank
stare, myoglobinuria, increased creatinine
phosphokinase

Tricyclic anti Dry mucosa, vasodilation, hypotension, seizures,

depressants ileus, altered mental status, pupillary dilation,
arrhythmias, widened QRS

Theophylline Nausea, vomiting, tachycardia, tremor, convul

sions, metabolic acidosis, hypokalemia, ECG
abnormalities

Adrenergic storm Pupillary dilation, hyperthermia, agitation,

(cocaine, am diaphoresis, seizures, tremor, anxiety, tactile
phetamines, hallucinations, dysrhythmias, active bowel
phenylpropan sounds, track marks, hypertension
olamine)

Sedative/hypnotics Respiratory depression, coma, hypothermia,

disconjugate eye movements

Anticholinergics Dry mucous membranes and skin, tachycardia,

fever, arrhythmias, urinary and fecal retention,
mental status change, pupillary dilation, flush
ing

Trauma
History: Allergies, Medications, Past medical history, Last meal, and Events
leading up to the injury (AMPLE). Determine the mechanism of injury and
details of the trauma.

I. Primary Survey: ABCDEs

A. Airway: Check for signs of obstruction (noisy breathing, inadequate air
exchange). Normal speech indicates a patent airway.
B. Breathing: Observe chest excursion. Auscultate chest.
C. Circulation: Heart rate, blood pressure, pulse pressure, level of con
sciousness, capillary refill.
D. Disability
(1) Level of Consciousness: Alert, response to verbal stimuli, response
to painful stimuli, unresponsive.
94 Trauma

(2) Neurological Deficit: Four extremity gross motor function, sensory

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

TABLE 9-1
DEVELOPMENTAL MILESTONES
Visual-Motor/
Age Gross Motor Problem Solving Language Social/Adaptive
1mo Raises head from Visually fixes, Alerts to sound Regards face
prone position follows to midline,
has tight grasp
2mo Holds head in No longer clenches Smiles socially Recognizes
midline, lifts fists tightly, (after being parent
chest off table follows object stroked or talked
past midline to)
3mo Supports on Holds hands open Coos (produces long Reaches for
forearms in prone at rest, follows in vowel sounds in familiar people
position, holds circular fashion, musical fashion) or objects,
head up steadily responds to visual anticipates
threat feeding
4mo Rolls over, supports Reaches with arms Laughs, orients to Enjoys looking
on wrists, shifts in unison, brings voice around
weight hands to midline
6mo Sits unsupported, Unilateral reach, Babbles, ah-goo, Recognizes that
puts feet in mouth uses raking razz, lateral someone is a
in supine position grasp, transfers orientation to bell stranger
objects
9mo Pivots when sitting, Uses immature Says mama, dada Starts exploring
crawls well, pulls pincer grasp, indiscriminately, environment,
to stand, cruises probes with gestures, waves plays gesture
forefinger, holds bye-bye, games (e.g.,
bottle, throws understands no pat-a-cake)
objects
12mo Walks alone Uses mature pincer Uses two words Imitates actions,
grasp, can make other than mama, comes when
a crayon mark, dada or proper called,
releases nouns, jargoning cooperates with
voluntarily (runs several dressing
unintelligible
words together
with tone or
inflection),
one-step command
with gesture
15mo Creeps up stairs, Scribbles in Uses 46 words, 1518mo: Uses
walks backward imitation, builds follows one-step spoon and cup
independently tower of 2 blocks command without
in imitation gesture
18mo Runs, throws Scribbles Mature jargoning Copies parent
objects from spontaneously, (includes in tasks
standing without builds tower of 3 intelligible words), (sweeping,
falling blocks, turns two 710 word dusting), plays
or three pages at vocabulary, knows in company of
a time 5 body parts other children
 Chapter 9 Development, Behavior, and Mental Health 229

TABLE 9-1
DEVELOPMENTAL MILESTONES (Continued)
Visual-Motor/
Age Gross Motor Problem Solving Language Social/Adaptive
24mo Walks up and down Imitates stroke Uses pronouns (I, Parallel play
steps without help with pencil, you, me)
builds tower of 7 inappropriately,
blocks, turns follows two-step
pages one at a commands,
time, removes 50-word
shoes, pants, etc. vocabulary, uses
2-word sentences
3yr Can alternate feet Copies a circle, Uses minimum of Group play,
going up steps, undresses 250 words, 3-word shares toys,
pedals tricycle completely, sentences, uses takes turns,
dresses partially, plurals, knows all plays well with
dries hands if pronouns, repeats others, knows
reminded, two digits full name, age,
unbuttons gender
4yr Hops, skips, Copies a square, Knows colors, says Tells tall tales,
alternates feet buttons clothing, song or poem from plays

9
going down steps dresses self memory, asks cooperatively
completely, questions with a group of
catches ball children
5yr Skips alternating Copies triangle, Prints first name, Plays competitive
feet, jumps over ties shoes, asks what a word games, abides
low obstacles spreads with means by rules, likes
knife to help in
household tasks
From Capute AJ, Biehl RF: Functional developmental evaluation: prerequisite to habilitation. Pediatr Clin North Am
1973;20:3; Capute AJ, Accardo PJ: Linguistic and auditory milestones during the first two years of life: a language
inventory for the practitioner. Clin Pediatr 1978;17:847; and Capute AJ etal: The Clinical Linguistic and Auditory
Milestone Scale (CLAMS): identification of cognitive defects in motor delayed children. Am J Dis Child 1986;140:694.
Rounded norms from Capute AJ etal: Clinical Linguistic and Auditory Milestone Scale: prediction of cognition in
infancy. Dev Med Child Neurol 1986;28:762.
 Chapter 1 Emergency Management 15

TABLE 1-3
COMA SCALES
Glasgow Coma Scale Modified Coma Scale for Infants
Activity Best Response Activity Best Response
EYE OPENING
Spontaneous 4 Spontaneous 4
To speech 3 To speech 3
To pain 2 To pain 2
None 1 None 1
VERBAL
Oriented 5 Coo/babbles 5
Confused 4 Irritable 4
Inappropriate words 3 Cries to pain 3
Nonspecific sounds 2 Moans to pain 2
None 1 None 1
MOTOR
Follows commands 6 Normal spontaneous movements 6
Localizes pain 5 Withdraws to touch 5
Withdraws to pain 4 Withdraws to pain 4
Abnormal flexion 3 Abnormal flexion 3
Abnormal extension 2 Abnormal extension 2
None 1 None 1
Data from Jennet B, Teasdale G: Aspects of coma after severe head injury. Lancet 1977;1:878, and James HE:
Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann 1986;15:16.
 Assessment of severity of an acute episode
Assess for presence of Red flag signs which suggest threat to life:
Altered sensorium (drowsy or very agitated)
Bradycardia
Poor pulse volume
Cyanosis (with 60 % oxygen)
Excessive use of accessory muscles or state of exhaustion
(vocalization limited to 1-2 words)
Excessive diaphoresis
Silent chest on auscultation
ABG: rate of rise of pCO2>5mm Hg/hr, pCO2>40 mm Hg,
pO2<60 mm Hg, metabolic acidosis (-BE>7-10)
SaO2 on room air < 92%
If Red flag signs are absent, grade severity of exacerbation as below :
Respiratory rate Accessory muscle
Score Wheezing present*
< 6 yrs > 6 yrs usage
0 < 30 < 20 None No apparent activity
1 31-45 21-35 Terminal expiration Questionable increase
with stethoscope
2 46-60 36-50 Entire expiration Increase apparent
with stethoscope
3 >60 >50 During inspiration
and expiration Maximum activity
without stethoscope
Add 0-3 Mild *If wheezing absent
Score 4-6 Moderate (due to minimal air
>6 Severe flow), score > 3
Ascertain the following information:
Duration of episode
Medications the child is already using as preventers
Reliever medications taken before reporting to doctor
Precipitating factors
Identify risk factors for acute severe asthma:
Previous exacerbations: Chronic steroid-dependent asthma
Prior intensive care admission / mechanical
ventilation / life threatening episode
Poor compliance with preventer therapy
Current exacerbation: Rapid onset and progress of symptoms
Frequent visits to doctor in preceding few days
Visit to emergency room in past 48 hours
Economic and logistic constraints to
healthcare access
 Step 4 Having diagnosed asthma, quantify the symptoms over a
period of time to assess severity
Grades of severity Symptoms Night time Peak expiratory
of asthma of airflow symptoms flow (PEF)*
obstruction
Grade 4
Severe Continuous Frequent < 60 % of
persistent Limited personal best
physical > 30 %
activity diurnal variation**
Grade 3
Moderate >once a day > once > 60 % - < 80 %
persistent a week of personal best or
Attacks affect > 30 %
activity diurnal variation**
Grade 2
Mild > once a > twice > 80 % of
persistent week but < a month personal best
once a day 20-30 %
diurnal variation**
Grade1
Mild < once a < twice > 80 % of
intermittent week a month personal best
Asymptomatic < 20 %
and normal diurnal variation**
between
attacks

* Not essential
** A diurnal variation of <10 % in PEF values is normal. Lowest PEF levels
are seen on waking and highest levels about 12 hours later.

Note:
Children with intermittent asthma but severe exacerbations should be
treated as having moderate persistent asthma.
 TABLE 7: DIAGNOSIS OF LEPTOSPIROSIS-MODIFIED FAINES CRITERIA
Name: Age: Sex: Occupation:
Residence (rural/urban ): Date:

PART A: Clinical Data Score Part B: Epidemiological factors Score

Headache 2 Rainfall 5
Fever 2 Contact with contaminated
Temp > 39 C 2 Environment 4
Conjunctival suffusion 4 Animal Contact 1
Meningism 4
Myalgia 4
Conjunctival suffusion Part C : Bacteriological Lab findings
Meningism 10 Isolation of leptospira in Culture
Myalgia Diagnosis certain
Jaundice 1 Positive Serology
Albuminuria / 2 ELISA IgM Positive 15
Nitrogen retension SAT - Positive 15
MAT- Single positive 15
in high titre
Rising titre / seroconversion
(paired sera) 25

Presumptive diagnosis of leptospirosis is made of:

Part A or part A & part B score : 26 or more
Part A, B, C (Total) : 25 or more
A score between 20 and 25 suggests leptospirosis as a possible diagnosis.

MANAGEMENT

Mild leptospirosis can be treated with Doxycycline or Amoxycillin or

Erythromycin and severe leptospirosis with I.V. Penicillin or Ceftriaxone.

Medicine Update 2008 Vol. 18 799 809

18
TABLE IV SCORING SYSTEM TO DIAGNOSE SPOTTED FEVER
GROUP (TOTAL SCORE = 35)

Clinical features Score Laboratory Score

Rural 1 Hemoglobin 9 g/dL(%) 1

Pets 1 Platelets <150,000 (cells/L) 1
Tick exposure 2 CRP 50 (mg/dL) 2
Tick bite 3 Serum albumin <3 g/dL 1
Conjunctival 2 Urine albumin 2+ 1
congestion (Non SGPT 100 (U/L) 2
exudative) Na 130 (mEg/L) 2
Maculopapular rash 1
Purpura 2
Palpable purpura/ 3
ecchymosis/
necrotic rash
Rash appearing 2
48-96 h after fever
Pedal edema 2
Rash on palms 3
and soles
Hepatomegaly 2
Lymphadenopathy 1

Total 25 10
Body Mass Index (BMI) percentiles

35 35

34 34

33 33

32 32

31 31
95
30 30

29 29

28 28
)
ese
27
t (Ob 27
le n
26 quiva 26
du lt e
A
25 28 25
nt
vale
24
tequi 24
A dul
23 25 23
)
22 we ight 22
r
nt (ove
al e
21
e quiv 21
50
dult
20 23 A 20

19 19

18 25 18

17 17

16
10
16

15 15
3
14 14

13 13

12 12

11 11

10 10
Kg 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Kg

AGE (Years)
5 TO 18 Years: Girls
Body Mass Index (BMI) percentiles

35 35

34 34

33 33

32 32

31 31

30 95 30

29 29

28 28

bese)
27 t (O 27
ivalen
qu
26
du lt e 26
28A
25 25
i va lent
qu
24
du lt e 24
25 A
23 23
t)
r weigh
22 ve 22
l e nt (o
a
21 lt equiv 21
du 50
23 A
20 20

19 19
25
18 18

17 17
10
16 16

15 3 15

14 14

13 13

12 12

11 11

10 10
Kg 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Kg

AGE (Years)
 TABLE 3

Blood Pressure Levels for Boys by Age and Height Percentile*

Systolic BP (mmHg) Diastolic BP (mmHg)

Age BP
(Year) Percentile Percentile of Height Percentile of Height
5th 10th 25th 50th 75th 90th 95th
5th 10th 25th 50th 75th 90th 95th

1 50th 80 81 83 85 87 88 89 34 35 36 37 38 39 39
90th 94 95 97 99 100 102 103 49 50 51 52 53 53 54
95th 98 99 101 103 104 106 106 54 54 55 56 57 58 58
99th 105 106 108 110 112 113 114 61 62 63 64 65 66 66

2 50th 84 85 87 88 90 92 92 39 40 41 42 43 44 44
90th 97 99 100 102 104 105 106 54 55 56 57 58 58 59
95th 101 102 104 106 108 109 110 59 59 60 61 62 63 63
99th 109 110 111 113 115 117 117 66 67 68 69 70 71 71

3 50th 86 87 89 91 93 94 95 44 44 45 46 47 48 48
90th 100 101 103 105 107 108 109 59 59 60 61 62 63 63
95th 104 105 107 109 110 112 113 63 63 64 65 66 67 67
99th 111 112 114 116 118 119 120 71 71 72 73 74 75 75

4 50th 88 89 91 93 95 96 97 47 48 49 50 51 51 52
90th 102 103 105 107 109 110 111 62 63 64 65 66 66 67
95th 106 107 109 111 112 114 115 66 67 68 69 70 71 71
99th 113 114 116 118 120 121 122 74 75 76 77 78 78 79

5 50th 90 91 93 95 96 98 98 50 51 52 53 54 55 55
90th 104 105 106 108 110 111 112 65 66 67 68 69 69 70
95th 108 109 110 112 114 115 116 69 70 71 72 73 74 74
99th 115 116 118 120 121 123 123 77 78 79 80 81 81 82

6 50th 91 92 94 96 98 99 100 53 53 54 55 56 57 57
90th 105 106 108 110 111 113 113 68 68 69 70 71 72 72
95th 109 110 112 114 115 117 117 72 72 73 74 75 76 76
99th 116 117 119 121 123 124 125 80 80 81 82 83 84 84

7 50th 92 94 95 97 99 100 101 55 55 56 57 58 59 59

90th 106 107 109 111 113 114 115 70 70 71 72 73 74 74
95th 110 111 113 115 117 118 119 74 74 75 76 77 78 78
99th 117 118 120 122 124 125 126 82 82 83 84 85 86 86

8 50th 94 95 97 99 100 102 102 56 57 58 59 60 60 61

90th 107 109 110 112 114 115 116 71 72 72 73 74 75 76
95th 111 112 114 116 118 119 120 75 76 77 78 79 79 80
99th 119 120 122 123 125 127 127 83 84 85 86 87 87 88

9 50th 95 96 98 100 102 103 104 57 58 59 60 61 61 62

90th 109 110 112 114 115 117 118 72 73 74 75 76 76 77
95th 113 114 116 118 119 121 121 76 77 78 79 80 81 81
99th 120 121 123 125 127 128 129 84 85 86 87 88 88 89

10 50th 97 98 100 102 103 105 106 58 59 60 61 61 62 63

90th 111 112 114 115 117 119 119 73 73 74 75 76 77 78
95th 115 116 117 119 121 122 123 77 78 79 80 81 81 82
99th 122 123 125 127 128 130 130 85 86 86 88 88 89 90
10 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
 Systolic BP (mmHg) Diastolic BP (mmHg)
Age BP
(Year) Percentile Percentile of Height Percentile of Height
5th 10th 25th 50th 75th 90th 95th
5th 10th 25th 50th 75th 90th 95th

11 50th 99 100 102 104 105 107 107 59 59 60 61 62 63 63

90th 113 114 115 117 119 120 121 74 74 75 76 77 78 78
95th 117 118 119 121 123 124 125 78 78 79 80 81 82 82
99th 124 125 127 129 130 132 132 86 86 87 88 89 90 90

12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79
95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83
99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

13 50th 104 105 106 108 110 111 112 60 60 61 62 63 64 64

90th 117 118 120 122 124 125 126 75 75 76 77 78 79 79
95th 121 122 124 126 128 129 130 79 79 80 81 82 83 83
99th 128 130 131 133 135 136 137 87 87 88 89 90 91 91

14 50th 106 107 109 111 113 114 115 60 61 62 63 64 65 65

90th 120 121 123 125 126 128 128 75 76 77 78 79 79 80
95th 124 125 127 128 130 132 132 80 80 81 82 83 84 84
99th 131 132 134 136 138 139 140 87 88 89 90 91 92 92

15 50th 109 110 112 113 115 117 117 61 62 63 64 65 66 66

90th 122 124 125 127 129 130 131 76 77 78 79 80 80 81
95th 126 127 129 131 133 134 135 81 81 82 83 84 85 85
99th 134 135 136 138 140 142 142 88 89 90 91 92 93 93

16 50th 111 112 114 116 118 119 120 63 63 64 65 66 67 67

90th 125 126 128 130 131 133 134 78 78 79 80 81 82 82
95th 129 130 132 134 135 137 137 82 83 83 84 85 86 87
99th 136 137 139 141 143 144 145 90 90 91 92 93 94 94

17 50th 114 115 116 118 120 121 122 65 66 66 67 68 69 70

90th 127 128 130 132 134 135 136 80 80 81 82 83 84 84
95th 131 132 134 136 138 139 140 84 85 86 87 87 88 89
99th 139 140 141 143 145 146 147 92 93 93 94 95 96 97

BP, blood pressure

* The 90th percentile is 1.28 SD, 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean. For research purposes,
the standard deviations in appendix table B1 allow one to compute BP Z-scores and percentiles for boys with height percentiles given
in table 3 (i.e., the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles). These height percentiles must be converted to height
Z-scores given by (5% = -1.645; 10% = -1.28; 25% = -0.68; 50% = 0; 75% = 0.68; 90% = 1.28; 95% = 1.645) and then computed
according to the methodology in steps 24 described in appendix B. For children with height percentiles other than these, follow steps
14 as described in appendix B.

Blood Pressure Tables 11

 TABLE 4

Blood Pressure Levels for Girls by Age and Height Percentile*

Systolic BP (mmHg) Diastolic BP (mmHg)

Age BP
(Year) Percentile Percentile of Height Percentile of Height
5th 10th 25th 50th 75th 90th 95th
5th 10th 25th 50th 75th 90th 95th

1 50th 83 84 85 86 88 89 90 38 39 39 40 41 41 42
90th 97 97 98 100 101 102 103 52 53 53 54 55 55 56
95th 100 101 102 104 105 106 107 56 57 57 58 59 59 60
99th 108 108 109 111 112 113 114 64 64 65 65 66 67 67

2 50th 85 85 87 88 89 91 91 43 44 44 45 46 46 47
90th 98 99 100 101 103 104 105 57 58 58 59 60 61 61
95th 102 103 104 105 107 108 109 61 62 62 63 64 65 65
99th 109 110 111 112 114 115 116 69 69 70 70 71 72 72

3 50th 86 87 88 89 91 92 93 47 48 48 49 50 50 51
90th 100 100 102 103 104 106 106 61 62 62 63 64 64 65
95th 104 104 105 107 108 109 110 65 66 66 67 68 68 69
99th 111 111 113 114 115 116 117 73 73 74 74 75 76 76

4 50th 88 88 90 91 92 94 94 50 50 51 52 52 53 54
90th 101 102 103 104 106 107 108 64 64 65 66 67 67 68
95th 105 106 107 108 110 111 112 68 68 69 70 71 71 72
99th 112 113 114 115 117 118 119 76 76 76 77 78 79 79

5 50th 89 90 91 93 94 95 96 52 53 53 54 55 55 56
90th 103 103 105 106 107 109 109 66 67 67 68 69 69 70
95th 107 107 108 110 111 112 113 70 71 71 72 73 73 74
99th 114 114 116 117 118 120 120 78 78 79 79 80 81 81

6 50th 91 92 93 94 96 97 98 54 54 55 56 56 57 58
90th 104 105 106 108 109 110 111 68 68 69 70 70 71 72
95th 108 109 110 111 113 114 115 72 72 73 74 74 75 76
99th 115 116 117 119 120 121 122 80 80 80 81 82 83 83

7 50th 93 93 95 96 97 99 99 55 56 56 57 58 58 59
90th 106 107 108 109 111 112 113 69 70 70 71 72 72 73
95th 110 111 112 113 115 116 116 73 74 74 75 76 76 77
99th 117 118 119 120 122 123 124 81 81 82 82 83 84 84

8 50th 95 95 96 98 99 100 101 57 57 57 58 59 60 60

90th 108 109 110 111 113 114 114 71 71 71 72 73 74 74
95th 112 112 114 115 116 118 118 75 75 75 76 77 78 78
99th 119 120 121 122 123 125 125 82 82 83 83 84 85 86

9 50th 96 97 98 100 101 102 103 58 58 58 59 60 61 61

90th 110 110 112 113 114 116 116 72 72 72 73 74 75 75
95th 114 114 115 117 118 119 120 76 76 76 77 78 79 79
99th 121 121 123 124 125 127 127 83 83 84 84 85 86 87

10 50th 98 99 100 102 103 104 105 59 59 59 60 61 62 62

90th 112 112 114 115 116 118 118 73 73 73 74 75 76 76
95th 116 116 117 119 120 121 122 77 77 77 78 79 80 80
99th 123 123 125 126 127 129 129 84 84 85 86 86 87 88
12 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
 Systolic BP (mmHg) Diastolic BP (mmHg)
Age BP
(Year) Percentile Percentile of Height Percentile of Height
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

11 50th 100 101 102 103 105 106 107 60 60 60 61 62 63 63

90th 114 114 116 117 118 119 120 74 74 74 75 76 77 77
95th 118 118 119 121 122 123 124 78 78 78 79 80 81 81
99th 125 125 126 128 129 130 131 85 85 86 87 87 88 89

12 50th 102 103 104 105 107 108 109 61 61 61 62 63 64 64

90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78
95th 119 120 121 123 124 125 126 79 79 79 80 81 82 82
99th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

13 50th 104 105 106 107 109 110 110 62 62 62 63 64 65 65

90th 117 118 119 121 122 123 124 76 76 76 77 78 79 79
95th 121 122 123 124 126 127 128 80 80 80 81 82 83 83
99th 128 129 130 132 133 134 135 87 87 88 89 89 90 91

14 50th 106 106 107 109 110 111 112 63 63 63 64 65 66 66

90th 119 120 121 122 124 125 125 77 77 77 78 79 80 80
95th 123 123 125 126 127 129 129 81 81 81 82 83 84 84
99th 130 131 132 133 135 136 136 88 88 89 90 90 91 92

15 50th 107 108 109 110 111 113 113 64 64 64 65 66 67 67

90th 120 121 122 123 125 126 127 78 78 78 79 80 81 81
95th 124 125 126 127 129 130 131 82 82 82 83 84 85 85
99th 131 132 133 134 136 137 138 89 89 90 91 91 92 93

16 50th 108 108 110 111 112 114 114 64 64 65 66 66 67 68

90th 121 122 123 124 126 127 128 78 78 79 80 81 81 82
95th 125 126 127 128 130 131 132 82 82 83 84 85 85 86
99th 132 133 134 135 137 138 139 90 90 90 91 92 93 93

17 50th 108 109 110 111 113 114 115 64 65 65 66 67 67 68

90th 122 122 123 125 126 127 128 78 79 79 80 81 81 82
95th 125 126 127 129 130 131 132 82 83 83 84 85 85 86
99th 133 133 134 136 137 138 139 90 90 91 91 92 93 93
 Chapter 27
Blood Chemistries and
Body Fluids
Kristin M. Arcara, MD

The determination of normal reference ranges of laboratory studies in

pediatric patients poses some major challenges. The available literature
is often limited due to the small sample sizes of patients in many studies

27
that have been used to derive these suggested normal ranges. Please use
great caution and be aware of this limitation when interpreting pediatric
laboratory studies.
The following values are compiled from the published literature and
from the Johns Hopkins Hospital Department of Laboratory Medicine.
Normal values vary with analytic method used. Consult your laboratory for
its analytic method and range of normal values and for less commonly
used parameters, which are beyond the scope of this text. Additional
normal laboratory values may be found in Chapters 10, 14, and 15.
A special thanks to Lori Sokoll, Ph. D., for her guidance in preparing
this chapter.
I. REFERENCE VALUES (TABLE 27-1)
Text continued on page 647
TABLE 27-1
REFERENCE VALUES
Conventional Units SI Units
ACID PHOSPHATASE
(Major sources: Prostate and erythrocytes)
Newborn 7.419.4U/L 7.419.4U/L
213yr 6.415.2U/L 6.415.2U/L
Adult male 0.511.0U/L 0.511.0U/L
Adult female 0.29.5U/L 0.29.5U/L
ALANINE AMINOTRANSFERASE (ALT)1,2
(Major sources: Liver, skeletal muscle, and myocardium)
Infant <5 days 650U/L 650U/L
Infant <12mo 1345U/L 1345U/L
13yr 545U/L 545U/L
46yr 1025U/L 1025U/L
79yr 1035U/L 1035U/L
1011yr
Female 1030U/L 1030U/L
Male 1035U/L 1035U/L
Continued

639
640 Part III Reference

TABLE 27-1
REFERENCE VALUES (Continued)
Conventional Units SI Units
ALANINE AMINOTRANSFERASE (ALT)1,2
(Major sources: Liver, skeletal muscle, and myocardium)
1213yr
Female 1030U/L 1030U/L
Male 1055U/L 1055U/L
1415yr
Female 530U/L 530U/L
Male 1045U/L 1045U/L
>16yr
Female 535U/L 535U/L
Male 1040U/L 1040U/L
ALBUMIN
(See Proteins)
ALDOLASE3
(Major sources: Skeletal muscle and myocardium)
1024mo 3.411.8U/L 3.411.8U/L
216yr 1.28.8U/L 1.28.8U/L
Adult 1.74.9U/L 1.74.9U/L
ALKALINE PHOSPHATASE4
(Major sources: Liver, bone, intestinal mucosa, placenta, and kidney)
Infant 150420U/L 150420U/L
210yr 100320U/L 100320U/L
Adolescent male 100390U/L 100390U/L
Adolescent female 100320U/L 100320U/L
Adult 30120U/L 30120U/L
AMMONIA2
(Heparinized venous specimen on ice analyzed within 30min)
Newborn 90150 mcg/dL 64107 mol/L
02wk 79129 mcg/dL 5692 mol/L
Infant/child 2970 mcg/dL 2150 mol/L
Adult 1545 mcg/dL 1132 mol/L
AMYLASE3
(Major sources: Pancreas, salivary glands, and ovaries)
03mo 030U/L 030U/L
36mo 050U/L 050U/L
612mo 080U/L 080U/L
>1yr 30100U/L 30100U/L
ANTINUCLEAR ANTIBODY (ANA)2
Negative <1:40
Patterns with clinical correlation:
Centromere: CREST
Nucleolar: Scleroderma
Homogeneous: Systemic lupus
erythematosus (SLE)
 Chapter 27 Blood Chemistries and Body Fluids 641

TABLE 27-1
REFERENCE VALUES (Continued)
Conventional Units SI Units
ANTISTREPTOLYSIN O TITER5
(Fourfold rise in paired serial specimens is significant)
Newborn Similar to mothers value
624mo 50 Todd units/mL
24yr 160 Todd units/mL
5yr 330 Todd units/mL
ASPARTATE AMINOTRANSFERASE (AST)2
(Major sources: Liver, skeletal muscle, kidney, myocardium, and erythrocytes)
010 days 47150U/L 47150U/L
10 day24mo 980U/L 980U/L

27
>24mo
Female 1335U/L 1335U/L
Male 1540U/L 1540U/L
BICARBONATE2,4
Newborn 1724mEq/L 1724mmol/L
Infant 1924mEq/L 1924mmol/L
2mo2yr 1624mEq/L 1624mmol/L
>2yr 2226mEq/L 2226mmol/L
BILIRUBIN (TOTAL)4,6
(Please see Chapter 18 for more complete information about neonatal hyperbilirubinemia
and acceptable bilirubin values)
Cord:
Term and preterm <2mg/dL <34 mol/L
01 days:
Term and preterm <8mg/dL <137 mol/L
12 days:
Preterm <12mg/dL <205 mol/L
Term <11.5mg/dL <197 mol/L
35 days:
Preterm <16mg/dL <274 mol/L
Term <12mg/dL <205 mol/L
Older infant:
Preterm <2mg/dL <34 mol/L
Term <1.2mg/dL <21 mol/L
Adult <1.5mg/dL <20.5 mol/L
BILIRUBIN (CONJUGATED)24
Neonate <0.6mg/dL <10 mol/L
Infants/children <0.2mg/dL <3.4 mol/L
BLOOD GAS, ARTERIAL (BREATHING ROOM AIR)2
pH PaO2 (mmHg) PaCO2 (mmHg) HCO3 (mEq/L)
Cord blood 7.28 0.05 18.0 6.2 49.2 8.4 1422
Newborn (birth) 7.117.36 824 2740 1322
510min 7.097.30 3375 2740 1322
30min 7.217.38 3185 2740 1322
Continued
642 Part III Reference

TABLE 27-1
REFERENCE VALUES (Continued)
BLOOD GAS, ARTERIAL (BREATHING ROOM AIR)2
pH PaO2 (mmHg) PaCO2 (mmHg) HCO3 (mEq/L)
60min 7.267.49 5580 2740 1322
1 day 7.297.45 5495 2740 1322
Child/adult 7.357.45 83108 3248 2028
NOTE: Venous blood gases can be used to assess acid-base status, not oxygenation. PCO2 averages 68mmHg higher
than PaCO2, and pH is slightly lower. Peripheral venous samples are strongly affected by the local circulatory and
metabolic environment. Capillary blood gases correlate best with arterial pH and moderately well with PaCO2.
Conventional Units SI Units
C-REACTIVE PROTEIN4 00.5mg/dL
CALCIUM (TOTAL)2
Premature neonate 6.211mg/dL 1.552.75mmol/L
010 days 7.610.4mg/dL 1.92.6mmol/L
10 d24mo 911mg/dL 2.252.75mmol/L
24mo12yr 8.810.8mg/dL 2.22.7mmol/L
1218yr 8.410.2mg/dL 2.12.55mmol/L
CALCIUM (IONIZED)3
01mo 3.96.0mg/dL 1.01.5mmol/L
16mo 3.75.9mg/dL 0.951.5mmol/L
118yr 4.95.5mg/dL 1.221.37mmol/L
Adult 4.755.3mg/dL 1.181.32mmol/L
CARBON DIOXIDE (CO2 CONTENT)2
(See Blood Gas, Arterial)
CARBON MONOXIDE (CARBOXYHEMOGLOBIN)
Nonsmoker 0.5%1.5% of total hemoglobin
Smoker 4%9% of total hemoglobin
Toxic 20%50% of total hemoglobin
Lethal >50% of total hemoglobin
Conventional Units Si Units
CHLORIDE (SERUM)3
06mo 97108mEq/L 97108mmol/L
612mo 97106mEq/L 97106mmol/L
Child/adult 97107mEq/L 97107mmol/L
CHOLESTEROL
(See Lipids)
CREATINE KINASE (CREATINE PHOSPHOKINASE)2
(Major sources: Myocardium, skeletal muscle, smooth muscle, and brain)
Newborn 1451,578U/L 1451,578U/L
>6wkAdult male 20200U/L 20200U/L
>6wkAdult female 20180U/L 20180U/L
CREATININE (SERUM)2
Cord 0.61.2mg/dL 53106 mol/L
Newborn 0.31.0mg/dL 2788 mol/L
Infant 0.20.4mg/dL 1835 mol/L
Child 0.30.7mg/dL 2762 mol/L
 Chapter 27 Blood Chemistries and Body Fluids 643

TABLE 27-1
REFERENCE VALUES (Continued)
Conventional Units SI Units
Adolescent 0.51.0mg/dL 4488 mol/L
Adult male 0.91.3mg/dL 80115 mol/L
Adult female 0.61.1mg/dL 5397 mol/L
ERYTHROCYTE SEDIMENTATION RATE (ESR)2
Child 010mm/hr
Adult male 015mm/hr
Adult female 020mm/hr
FERRITIN2
Newborn 25200ng/mL 56450pmol/L
1mo 200600ng/mL 4501,350pmol/L

27
25mo 50200ng/mL 112450pmol/L
6mo15yr 7140ng/mL 16315pmol/L
Adult male 20250ng/mL 45562pmol/L
Adult female 10120ng/mL 22270pmol/L
FIBRINOGEN
(See Chapter 14)
FOLATE (SERUM)3
Newborn 1672ng/mL 1672nmol/L
Child 420ng/mL 420nmol/L
Adult 1063ng/mL 1063nmol/L
FOLATE (RBC)2
Newborn 150200ng/mL 340453nmol/L
Infant 74995ng/mL 1682,254nmol/L
216yr >160ng/mL >362nmol/L
>16yr 140628ng/mL 3171,422nmol/L
GALACTOSE2
Newborn 020mg/dL 01.11mmol/L
Older child <5mg/dL <0.28mmol/L
GAMMA-GLUTAMYL TRANSFERASE (GGT)2,5
(Major sources: Liver [biliary tree] and kidney)
Cord 37193U/L 37193U/L
01mo 13147U/L 13147U/L
12mo 12123U/L 12123U/L
24mo 890U/L 890U/L
4mo10yr 532U/L 532U/L
1015yr 524U/L 524U/L
Adult male 1149U/L 1149U/L
Adult female 732U/L 732U/L
GLUCOSE (SERUM)2,5
Preterm 2060mg/dL 1.13.3mmol/L
Newborn, <1 day 4060mg/dL 2.23.3mmol/L
Newborn, >1 day 5090mg/dL 2.85.0mmol/L
Child 60100mg/dL 3.35.5mmol/L
>16yr 70105mg/dL 3.95.8mmol/L
Continued
644 Part III Reference

TABLE 27-1
REFERENCE VALUES (Continued)
Conventional Units SI Units
HAPTOGLOBIN2
Newborn 548mg/dL 50480mg/L
>30 days 26185mg/dL 2601,850mg/L
HEMOGLOBIN A1C7
Normal 4.5%5.6%
At risk for diabetes 5.7%6.4%
Diabetes mellitus 6.5%
HEMOGLOBIN F, % TOTAL HEMOGLOBIN [MEAN (SD)]2
1 day 77.0 (7.3)
5 days 76.8 (5.8)
3wk 70.0 (7.3)
69wk 52.9 (11)
34mo 23.2 (16)
6mo 4.7 (2.2)
811mo 1.6 (1.0)
Adult <2.0
IRON2
Newborn 100250 mcg/dL 17.944.8 mol/L
Infant 40100 mcg/dL 7.217.9 mol/L
Child 50120 mcg/dL 9.021.5 mol/L
Adult male 65175 mcg/dL 11.631.3 mol/L
Adult female 50170 mcg/dL 9.030.4 mol/L
LACTATE2,3
Capillary blood:
090 days 932mg/dL 1.13.5mmol/L
324mo 930mg/dL 1.03.3mmol/L
218yr 922mg/dL 1.02.4mmol/L
Venous 4.519.8mg/dL 0.52.2mmol/L
Arterial 4.514.4mg/dL 0.51.6mmol/L
LACTATE DEHYDROGENASE (AT 37C)2
(Major sources: Myocardium, liver, skeletal muscle, erythrocytes, platelets, and lymph nodes)
04 days 290775U/L 290775U/L
410 days 5452,000U/L 5452,000U/L
10 days24mo 180430U/L 180430U/L
24mo12yr 110295U/L 110295U/L
>12yr 100190U/L 100190U/L
LEAD2
Child <10 mcg/dL <0.48 mol/L
LIPASE3
030 days 655U/L 655U/L
16mo 429U/L 429U/L
612mo 423U/L 423U/L
>1yr 332U/L 332U/L
 Chapter 27 Blood Chemistries and Body Fluids 645

TABLE 27-1
REFERENCE VALUES (Continued)

LDL (mg/dL)
Near/ HDL
Cholesterol (mg/dL) Above (mg/dL)
Desirable Borderline High Optimal optimal Borderline High Desirable
LIPIDS8,9
Child/ <170 170199 >200 <110 110129 >130 >35
adolescent
Adult <200 200239 <240 <100 100129 130159 >160 4060
Conventional Units SI Units
MAGNESIUM2 1.262.1mEq/L 0.631.05mmol/L

27
METHEMOGLOBIN2 0.78% ( 0.37%) of total hemoglobin
OSMOLALITY2 275295mOsm/kg 275295mmol/kg
PHENYLALANINE2
Preterm 2.07.5mg/dL 121454 mol/L
Newborn 1.23.4mg/dL 73206 mol/L
Adult 0.81.8mg/dL 48109 mol/L
PHOSPHORUS2
09 days 4.59.0mg/dL 1.452.91mmol/L
10 days24mo 46.5mg/dL 1.292.10mmol/L
39yr 3.25.8mg/dL 1.031.87mmol/L
1015yr 3.35.4mg/dL 1.071.74mmol/L
>15yr 2.44.4mg/dL 0.781.42mmol/L
PORCELAIN10 9.025.04mg/dL 5.031.03mmol/L
POTASSIUM2
Preterm 3.06.0mEq/L 3.06.0mmol/L
Newborn 3.75.9mEq/L 3.75.9mmol/L
Infant 4.15.3mEq/L 4.15.3mmol/L
Child 3.44.7mEq/L 3.44.7mmol/L
Adult 3.55.1mEq/L 3.55.1mmol/L
PREALBUMIN3
Newborn 739mg/dL
16mo 834mg/dL
6mo4yr 1236mg/dL
46yr 1230mg/dL
619yr 1242mg/dL
PROTEIN ELECTROPHORESIS (g/dL)2
Age Total Protein Albumin -1 -2
Cord 4.88.0
Premature 3.66.0
Newborn 4.67.0
015 day 4.47.6 3.03.9 0.10.3 0.30.6 0.40.6 0.71.4
15 day1yr 5.17.3 2.24.8 0.10.3 0.50.9 0.50.9 0.51.3
Continued
646 Part III Reference

TABLE 27-1
REFERENCE VALUES (Continued)
PROTEIN ELECTROPHORESIS (g/dL)2
Age Total Protein Albumin -1 -2
12yr 5.67.5 3.65.2 0.10.4 0.51.2 0.51.1 0.51.7
316yr 6.08.0 3.65.2 0.10.4 0.51.2 0.51.1 0.51.7
16yr 6.08.3 3.95.1 0.20.4 0.40.8 0.51.0 0.61.2
Conventional Units SI Units
PYRUVATE3 0.71.32mg/dL 0.080.15mmol/L
RHEUMATOID FACTOR2 <30U/mL
SODIUM1
<1yr 130145mEq/L 130145mmol/L
>1yr 135147mEq/L 135147mmol/L
TOTAL IRON-BINDING CAPACITY (TIBC)2
Infant 100400 mcg/dL 17.971.6 mol/L
Adult 250425 mcg/dL 44.876.1 mol/L
TOTAL PROTEIN
(See Proteins)
TRANSAMINASE (SGOT)
(See Aspartate aminotransferase [AST])
TRANSAMINASE (SGPT)
(See Alanine aminotransferase [ALT])
TRANSFERRIN2
Newborn 130275mg/dL 1.302.75g/L
3mo16yr 203360mg/dL 2.033.6g/L
Adult 215380mg/dL 2.153.8g/L
TOTAL TRIGLYCERIDE3
Conventional Units
(mg/dL) SI Units (mmol/L)
Male Female Male Female
07 day 21182 28166 0.242.06 0.321.88
830 day 30184 30165 0.342.08 0.341.86
3190 day 40175 35282 0.451.98 0.43.19
91180 day 45291 50355 0.513.29 0.574.01
181365 day 45501 36431 0.515.66 0.414.87
13yr 27125 27125 0.311.41 0.311.41
46yr 32116 32116 0.361.31 0.361.31
79yr 28129 28129 0.321.46 0.321.46
1019yr 24145 37140 0.271.64 0.421.58
Conventional Units SI Units
TROPONIN-I3
030 day <4.8 mcg/L
3190 day <0.4 mcg/L
36mo <0.3 mcg/L
712mo <0.2 mcg/L
118yr <0.1 mcg/L
 Chapter 27 Blood Chemistries and Body Fluids 647

TABLE 27-1
REFERENCE VALUES (Continued)
Conventional Units SI Units
UREA NITROGEN1,2
Premature (<1wk) 325mg/dL 1.18.9mmol/L
Newborn 219mg/dL 0.76.7mmol/L
Infant/child 518mg/dL 1.86.4mmol/L
Adult 620mg/dL 2.17.1mmol/L
URIC ACID3,5
030 day 1.04.6mg/dL 0.0590.271mmol/L
112mo 1.15.6mg/dL 0.0650.33mmol/L
15yr 1.75.8mg/dL 0.10.35mmol/L
611yr 2.26.6mg/dL 0.130.39mmol/L

27
Male 1219yr 3.07.7mg/dL 0.180.46mmol/L
Female 1219yr 2.75.7mg/dL 0.160.34mmol/L
VITAMIN A (RETINOL)2,3
Preterm 1346 mcg/dL 0.461.61 mol/L
Full term 1850 mcg/dL 0.631.75 mol/L
16yr 2043 mcg/dL 0.71.5 mol/L
712yr 2049 mcg/dL 0.91.7 mol/L
1319yr 2672 mcg/dL 0.92.5 mol/L
VITAMIN B1 (THIAMINE)2 4.510.3 mcg/dL 106242 mol/L
VITAMIN B2 (RIBOFLAVIN) 424 mcg/dL 106638nmol/L
VITAMIN B12 (COBALAMIN)2
Newborn 1601,300pg/mL 118959pmol/L
Child/adult 200835pg/mL 148616pmol/L
VITAMIN C (ASCORBIC ACID)2 0.42.0mg/dL 23114 mol/L
VITAMIN D3 1665pg/mL 42169pmol/L
(1,25-dIhYDROXY-VITAMIN D)2
VITAMIN E1,2,3
Preterm 0.53.5mg/L 18mol/L
Full term 1.03.5mg/L 28mol/L
112yr 3.09.0mg/L 721mol/L
1319yr 6.010.0mg/L 1423mol/L
ZINC2 70120 mcg/dL 10.718.4mmol/L
CREST: Calcinosis, Raynauds syndrome, Esophageal dysmotility, Sclerodactyly, Telangiectasia

II. EVALUATION OF BODY FLUIDS

A. Evaluation of Transudate Versus Exudate (Table 27-2)
B. Evaluation of Cerebrospinal Fluid (Table 27-3)
C. Evaluation of Synovial Fluid (Table 27-4)
648 Part III Reference

TABLE 27-2
EVALUATION OF TRANSUDATE VS. EXUDATE (PLEURAL, PERICARDIAL,
OR PERITONEAL FLUID)
Measurement* Transudate Exudate
Protein (g/dL) <3.0 >3.0
Fluid:serum ratio <0.5 0.5
LDH (IU) <200 200
Fluid:serum ratio (isoenzymes not useful) <0.6 0.6
WBCs <10,000/L >10,000/L
RBCs <5,000 >5,000
Glucose >40 <40
pH >7.2 <7.2
NOTE: Amylase >5,000U/mL or pleural fluid:serum ratio > 1 suggests pancreatitis.
*Always obtain serum for glucose, LDH, protein, amylase, and so forth.

All of the following criteria do not have to be met for consideration as an exudate.

In peritoneal fluid, WBC count >800/L suggests peritonitis.

Collect anaerobically in a heparinized syringe.

LDH, Lactate dehydrogenase; RBCs, red blood cells; WBCs, white blood cells.
Data from Nichols DG, Ackerman AD, Carcillo JA, etal: Rogers textbook of pediatric intensive care, 4th ed. Baltimore,
Williams & Wilkins, 2008.

TABLE 27-3
EVALUATION OF CEREBROSPINAL FLUID
Age4,11 WBC count/L (median) 95th percentile
028 d 012* (3) 19
2956 d 06* (2) 9
Child 07
Conventional Units SI Units
GLUCOSE4,12
Preterm 2463mg/dL 1.33.5mmol/L
Term 34119mg/dL 1.96.6mmol/L
Child 4080mg/dL 2.24.4mmol/L
PROTEIN4,12,13
Preterm 65150mg/dL 0.651.5g/L
014d 79 (23) mg/dL 0.79 (0.23) g/L
1528d 69 (20) mg/dL 0.69 (0.20) g/L
2942d 58 (17) mg/dL 0.58 (0.17) g/L
4356d 53 (17) mg/dL 0.53 (0.17) g/L
Child 540mg/dL 540mg/dL
OPENING PRESSURE (LATERAL RECUMBENT POSITION4,14)
Newborn 811cm H2O
118 years 11.528cm H2O*
Respiratory variations 0.51cm H2O
CSF, Cerebrospinal fluid; PMNs, polymorphonuclear lymphocytes; WBC, white blood cell.
*Up to 90th percentile

Mean (SD)
 TABLE 27-4
CHARACTERISTICS OF SYNOVIAL FLUID IN THE RHEUMATIC DISEASES
Synovial Mucin Miscellaneous
Group Condition Complement Color/Clarity Viscosity Clot WBC Count PMN (%) Findings
Noninflammatory Normal N Yellow G <200 <25
Clear
Traumatic arthritis N Xanthochromic FG <2,000 <25 Debris
Turbid
Osteoarthritis N Yellow FG 1,000 <25
Clear
Inflammatory Systemic lupus erythematosus Yellow N N 5,000 10 Lupus cells
Clear
Rheumatic fever N Yellow F 5,000 1050
Cloudy
Juvenile rheumatoid arthritis N Yellow Poor 15,00020,000 75
Cloudy
Reiters syndrome Yellow Poor 20,000 80 Reiters cells
Opaque
Pyogenic Tuberculous arthritis N Yellow-white Poor 25,000 5060 Acid-fast bacteria
Cloudy
Septic arthritis Serosanguinous Poor 50,000300,000 >75 Low glucose, bacteria
Turbid
F, Fair; G, good; H, high; N, normal; PMN, polymorphonuclear leukocyte; VH, very high; WBC, white blood cell; , decreased; , increased.
From Cassidy JT, Petty RE: Textbook of pediatric rheumatology, 5th ed. Philadelphia, WB Saunders, 2005.
Chapter 27 Blood Chemistries and Body Fluids 649

27
650 Part III Reference

III. CONVERSION FORMULAS

A. Temperature
1. To convert degrees Celsius to degrees Fahrenheit:
([9 / 5] Temperature) + 32
2. To convert degrees Fahrenheit to degrees Celsius:
(Temperature 32) (5 / 9)
B. Length and Weight
1. Length: To convert inches to centimeters, multiply by 2.54.
2. Weight: To convert pounds to kilograms, divide by 2.2.
REFERENCES