Clinical Approach to Common Cases PDF

Clinioal Approach to Common Cases Structure 16.1 Child with Fever 16.5 Child with Congenital Heart Disease (CH D) 16.2 Child with Loose Stools 16.6 Child with Seizures 16.3 Child with Edema...

Clinioal Approach to Common Cases Structure 16.1 Child with Fever 16.5 Child with Congenital Heart Disease (CH D) 16.2 Child with Loose Stools 16.6 Child with Seizures 16.3 Child with Edema 16.7 Child with Hemiplegia 16.4 Child with Pallor 16.1 CHILD WITH FEVER localizing signs" and "fever of unknown origin". A. Definition and Classification a. Fever without localizing signs: Refers to short 1. Fever ofShort Duration (less than i 4 days) duration fever (38OC) of more give a clue to the etiology of fever. than 3 weeks duration documented by a 2. Fever of Prolonged Duration health care provider, for which the specific (more than 14 days) diagnosis could not be established even Fever lasting for more than 2 weeks is after 1 week of admission and investigations in a hospital setting. considered prolonged fever. Infections remain the most important cause of prolonged fever. Now we will discuss the chief complaints, However, it can also be caused by non- negative history, and differential diagnoses of infectious illnesses such as collagen vascular the most common clinical scenarios where the disease, malignancies, and certain endocrine, major presenting illness is fever. hematological, and neurological disorders. B. Fever of Short Duration 3. Fever without Focus (Less than 14 Days) Fever not presenting with any other symptom Common clinical scenarios in children complex is referred to asfever withoutfocus. It presenting with short duration fever are listed is further categorized into "fever without as follows: 557 mebooksfree.com  Clinical Methods in Pediatrics 1. Fever less than 14 days without any major Approach to Diagnosis association Possible diagnoses with explanation are 2. Fever with cough tabulated in Table 16.1. Fever with cough with breathlessness/fast DJ breathing 2. Fever with Cough (without Fever with rash breathlessness).00.“?l Fever with jaundice Duration and character of cough can give Fever with pain in abdomen important clues towards underlying Fever with burning micturition etiology. Cough can be acute, recurrent, or Fever with abnormal movements and/or persistent. Ask about onset, aggravating/ altered sensorium relieving factors, postural variation, seasonal variation, paroxysmal nature, and presence 9 Fever with skin boils 10. Fever with joint pains of sputum. Also ask about noisy breathing, diurnal variation, family history, and 1. Fever 50 / min; 1—5 yr: RR rash all over the body >40 / min. In each of these scenarios, ask for the Lower Chest indrawing Visible inward move- following: ment of lower part of the chest wall with i. Day of onset of rash inspiration. It is suggestive of involvement of ii. Type and pattern of rash (area of involve- lower respiratory tract. It increases as the ment, change in appearance of rash) severity of illness increases. iii. Other characteristics Strider Noisy harsh low-pitched breathing Table 16.4 provides an approach to sound predominantly heard during inspiration diagnosis for a child presenting with fever and suggests stridor which occurs due to rash, based on the day of onset of rash, type of obstruction in the upper airway. rash, and clinical presentation. Wheezing Noisy musical high-pitched breathing sound predominantly heard during 5. Fever with Jaundice expiration suggests wheeze which is Table 16.5 provides an approach to diagnosis characteristic of obstruction of lower airways. for a child presenting with fever and jaundice, based on the history and clinical presentation. Negative History There is no history of bluish discoloration of 6. Fever with Pain in Abdomen lips (central cyanosis), lethargy, refusal to In the absence of jaundice, follow the feed, altered sensorium convulsions, head differential diagnoses approach given in nodding, audible grunt in an uncomplicated Table 16.6. case. Presence of any of these signs in a child with 7. Fever with Burning Micturition fever, cough, and breathing problem indicates Table 16.7 provides an approach to diagnosis hypoxia due to severe disease that may require and probable etiology of fever with burning oxygenation and other supportive measures. micturition in an older child. Approach to Diagnosis 8. Fever with Abnormal Movements Follow the clues from history and clinial and/or Altered Sensorium presentation to arrive at a possible diagnosis Elicit the following history to assess the area in a child presenting with fever, cough, and of brain involvement: breathlessness (Table 16.3). 0 Focal seizures (suggests unilateral 4. Fever with Rash involvement of brain parenchyma) The child may present with any of the 0 Altered sensorium (suggests encephalitis or following scenarios: encephalopathy) 0 Tonic posturing (suggests cerebral edema Case I: A 3-year-old child presents with due to raised intracranial pressure) i. Fever, cough, coryza x 3 days; and 0 Cranial nerve deficit (suggests brainstem ii. Reddish maculopapular rash appearing involvement) on day 3 of fever OR 0 Limb weakness (suggests motor system involvement) Case II: A 6-year-old child presents with fever 0 Paresthesias, tingling, numbness (suggests x 2 days and a vesicular rash for 1 day OR sensory system involvement) mebooksfree.com  Clinical Approach to Common Cases Table 16.3 Approach to diagnosis of fever with cough and breathlessness Clinical presentation Possible diagnosis Common etiology Hoarse voice, noisy Laryngotracheobronchitis/ Parainfluenza type A/B, breathing during croup influenza type A/B inspiration Acute epiglottitis H. influenzae type B Diphtheria with Corynebacterium obstruction diphtheriae Cough, fast breathing/ Pneumonia AgeuptoZmonths:Gram- difficult breathing, negative organisms, examination reveals Strept. pyogenes, crepitations over lungs Chlamydia Elicit the history of following symptoms Young age (< 3 ”70—5 yr) Age 2 "10-5 Yrs: with acute onset illness H. inf/uenzae, 1' Noisy breathing favors bronchopneumonia Strept. pneumoniae, 2. Lower chest indrawing Staphylococcus aureus, Strept. pyogenes,. Bluish discoloration of DJ viruses, lips (central cyanosis) Mycoplasma. Altered sensorium ©OO\I®U‘I-l> While older age >5 years Age >5yrs: Streptococcus. Lethargy favors lobar pneumonia pneumoniae,. Chest pain Staphylococcus aureus, viruses, Mycop/asma. Feed intolerance pneumoniae - Suck—rest—suck cycle First episode of wheeze Bronchiolitis Respiratory syncytial _ Feeding diaphoresis, in a child below 2 years virus failure to thrive Of 389/ preceded by rhinorrhea, cold, 10. Recurrent episodes sneezing, fever, red eyes. in ast p Wheezy child. History Wheezy RTI Can be secondary to any of similar episodes in OR viral or bacterial past, history of multitrigger wheeze infection of the nebulization in past, respiratory tract age less than 5 years Chest pain (indicates Empyema Staphylococcus aureus, pleural involvement) OR Strept. pneumoniae, Lobar pneumonia with Strept. pyogenes synpneumonic effusion Feed intolerance, Congestive heart failure Congenital heartdisease suck-rest-suck cycle, leading to increased feeding diaphoresis, blood flow to lungs: failure to thrive, and 0 VSD, PDA—acyanotic history of recurrent heart disease episodes 0 TGA—cyanotic heart disease mebooksfree.com  Clinical Methods in Pediatrics Table 16.4 Approach to diagnosis of a child with fever and rash Day of onset of rash Type of rash Clinical presentation Possible diagnosis Day 1—2 of fever Maculopapular to Typically begins within vesicular rash, lesions 24 hours of onset of fever, Chickenpox present in multiple stages Spares palms and soles Day 3—4 of fever Maculopapular rash Koplik spots in mouth beginning from face or associated with conjunctival Measles neck, spreading congestion, coryza. Usually centrifugally leaves dark pigmentation Day 1—5 of fever Generalized erythematous Palmoplantar erythema present, rash over extremities and itching present, other non- face which blanches on specific symptoms present, Dengue or pressure not associated with Chikungunya cough/cold Day 1—5 of fever Maculopapular rash Forchheimer sign: Petechiae beginning from face/fore- over soft palate head and spreading towards Associated with painful Rubella trunk and disappearing posterior auricular in the same manner lymphadenopathy Day 4—5 of fever Malar rash with slapped Typical slapped cheek Erythema cheek appearance appearance infectiosum (fifth followed by erythematous disease) caused by macular—morbilliform rash Parvovirus 819 over extremities Day 6—7 of fever Salmon colored, blanchable, Occur due to bacterial emboli Typhoid rash maculopapular rashes to skin, resolve within 2—5 days over trunk (Rose spots) Rash appearing Maculopapular rash with Strawberry tongue, red/ after 6—7 days of generalized erythematous cracked lips, unilateral non-resolving fever skin with periungal conjunctivitis and cervical Kawasaki disease desquamation and edema lymphadenopathy of hands and feet Rash appearing Maculopapular rash No prodromal symptoms after some drug occurring within 3—5 days Drug history present Drug rash intake of certain drugs mebooksfree.com  Clinical Approach to Common Cases Table 16.5 Approach to diagnosis of fever with jaundice History Clinical presentation Possible diagnosis Common etiology Prodromal phase of low Acute viral hepatitis Hepatitis A virus to moderate grade fever, (feco-oral transmission) Hepatitis E virus headache, malaise Elicit the history of following followed by jaundice. symptoms to get a clue to It may be associated with the underlying etiology: mild vomiting, anorexia 1. Exposure to persons with and pain m upper similar illness abdomen. There may be history of similar cases 2. Travel to endemic area in neighborhood or similar cases in neigtUVhOOd Prodromal phase (as Acute viral hepatitis Hepatitis B virus 3. Blood transfusion or above) fOllOWGOl by (blood-borne) Hepatitis C virus sexual contact or [N jaundice. This may be drug abuse associated with arthralgia or arthritis along with a 4. Family history of jaundice , , maculopapular rash. or neurological illness There may be a history of Presence of features of blood transfusion or hepatic failure like ascites, sexual contact or [N altered sensorium, drug abuse hematemesis, malena Moderate to high grade Enteric hepatitis Salmonella typhi suggests liver cell fever with toxic look. failure and hepatic Jaundice is mild encephalopathy High grade fever with Severe malaria, or Plasmodium sp. chills and rigors Severe dengue Dengue virus Decreased urine output Leptospirosis/severe Leptospira, malaria Plasmodium sp. Abdominal pain Cholangitis Salmonella, Anerobes 0 Ataxia, nystagmus (suggests cerebellar An approach to clinical and etiological involvement) diagnosis, based on history and clinical 0 Abnormal movements like chorea, presentation in a child with fever and seizures athetosis, tremors (suggests basal ganglia and/or altered sensorium is provided in involvement) Table 16.8. 0 Urinary or fecal retention / incontinence (suggests bladder /bowel involvement) mebooksfree.com  Clinical Methods in Pediatrics Table 16.6 Approach to diagnosis of a child with fever with pain abdomen (without jaundice) Points in history Clinical presentation Possible diagnosis Common etiology Loose stool mixed with Dysentery Shige/la, EHEC, EIEC blood Crampy abdominal pain Abdominal lump, red lntussusception current stools High grade fever with Liver abscess Staphylococcus Elicit the history of the chills, along with severe (upper abdominal pain) aureus following symptoms: pain on right side of the 1. Loose stools mixed with abdomen blood Acute appendicitis Gram negative 2. Preceding viral illness (lower abdomen) infections, like mumps or trauma Amoebic infections Fever with chills and Pyelonephritis Gram-negative 3. History of cough, cold, rigors, associated with organisms including or fast breathing flank pain, vomiting, E. COli (80%), urinary complaints, etc. Klebsiella, May find abdominal Enterobacter. mass on palpation Gram-positive organisms including Staph. aureus, and Enterococcus Preceding history of Acute pancreatitis Drugs (anti retroviral, preauricular swelling L-asparaginase) (mumps) OR trauma Cough/cold/fast breathing Acute tonsillitis, Pneumonia Table 16.7 Approach to diagnosis of a child with fever and burning micturition Points in history* Clinical presentation Diagnosis Common etiology Dysuria, urgency, Cystitis Gram-negative Elicit the history of following frequency, suprapubic pain, organisms including symptoms to get a clue to the urinary incontinence E. COli (80%), underlying etiology: Klebsie/la, Entero- 1.Dysuria, urgency, bacter, Gram-positive frequency organisms including 2. Lower abdominal pain Staph. aureus 3. Itching, foul smelling and discharge per vaginum Enterococcus Dysuria, itching, foul Urethritis 0 Infections: E. coli, smelling discharge, bleeding Chlamydia at the beginning of trachomatis micturition 0 Bladder stones, ureterocele *Suspect pyelonephritis, if fever is high along with chills and rigor. mebooksfree.com  Clinical Approach to Common Cases Table 16.8 Approach to clinical diagnosis of a child with fever and seizure Clinical presentation Possible diagnosis Common etiology Age 6 months—5 years Febrile seizure Upper respiratory Seizure at the peak of fever tract infections, viral No altered sensorium fevers, urinary tract No neurological deficit infections, gastro- No neck rigidity intestinal infections Past history of similar episode i Acute onset febrile illness Acute pyogenic Age 2 yr: photophobia N. meningitidis, S. pneumoniae. Neck rigidity U"! Acute onset febrile illness Acute febrile Viral encephalitis 6. History of preceding viral Altered sensorium ++ encephalopathy (arboviruses, herpes illness Headache, vomiting i viruses, entero- 7. Family history of similar 0 Focal neurological deficit viruses, measles, and meningeal signs mumps, adenovirus), illness usually absent cerebral malaria, Feature of raised intracranial enteric encephalo pressure (ICP) frequently pathy present Fever >5 days Tubercular Mycobacterium Altered sensorium and/or meningitis tuberculosis unconsciousness Headache, vomiting + Meningeal signs + Focal neurological deficit i Cranial nerve involvement + Features of raised ICP: Acute onset illness Brain abscess Staphylococcus Focal seizures aureus, Focal neurological deficit streptococci, Features of raised ICP i anaerobes, Gram- negative organisms like Proteus, Pseudomonas, Citrobacter and Hemophilus inf/uenzae mebooksfree.com  Clinical Methods in Pediatrics 9. Fever 2 weeks: Table 16.9 History of present illness and differential diagnosis of fever persisting more than 2 weeks Nature of illness Clinical presentation Etiology Infections 0 History of cough with sputum/fast breathing Tuberculosis 0 Flank pain, dysuria, urgency, frequency, Urinary tract infections foul smelling urine 0 History of abdominal pain, constipation or Typhoid fever diarrhea, toxic look, splenomegaly 0 Recurrent infections, significant weight loss, HIV infection, systemic loss of appetite fungal infections Inflammatory 0 Joint pain or joint swelling with restriction of Juvenile idiopathic arthritis, disorders movement systemic lupus erythe- 0 Rash over face/body matosus, Kawasaki disease, 0 Nodular swellings over body other connective tissue disorders Malignancies 0 Paleness of body, bleeding spots over skin or mucosa, Lymphoma, leukemia, brain 0 Nodular swellings over body tumors, neuroblastoma, 0 Abdominal distension Wilms’ tumor 0 Bony pains Endocrine causes 0 Excessive sweating, palpitations, proptosis Thyrotoxicosis 0 Polyuria, polydipsia Diabetes insipidus Hematological 0 Paleness of body Agranulocytosis, hemolytic disorders 0 Lump abdomen or abdominal distension anemia, disorders of T and 0 Recurrent infections B cells, immune deficiency disorders, malignancy Neurological 0 Excessive sweating Familial dysautonomia, disorders anhidrotic ectodermal dysplasia, hypothalamic and third ventricularlesions Miscellaneous 0 No major associations except for history of drugs Drug fever, factitious fever causes mebooksfree.com  Clinical Approach to Common Cases 567 0 History of cough with sputum/fast 0 History of joint pain or joint swelling with breathing (respiratory system) restriction of movement (juvenile idiopathic 0 History of abdominal distension, jaundice, arthritis) hematemesis, malena (hepatobiliary system) 0 History of nodular swellings (for 0 History of persistent diarrhea, chronic malignancies) diarrhea, malena, hematochezia (gastro- 0 History of abnormal movements, altered intestinal system) sensorium, focal neurological deficit (CNS) 0 History of paleness of body, bleeding spots 0 History of recurrent boils, significant weight over skin, mucosa (reticuloendothelial loss, loss of appetite (immune deficiency system, malignancies) state) 0 History of flank pain, dysuria, urgency, Examination findings that may help to frequency, foul smelling urine (genito- differentiate between various causes of urinary system) prolonged fever include presence of lympha- 0 History of rash over face / body (collagen denopathy, rash, arthritis, and hepatospleno- vascular disorders) megaly (Table 16.10). Table 16.10 Examination findings and differential diagnosis of fever persisting for more than 2 weeks Physical finding Duration of fever Less than 2 weeks More than 2 weeks Hepatomegaly Infections: Acute viral hepatitis, liver Chronic hepatitis, amebic liver abscess, abscess, enteric fever, dengue, enteric fever, scrub typhus scrub typhus Hematological: Sickle cell anemia Acute leukemia with crisis Malignancy: Acute leukemia Acute leukemia, lymphoma, hepatoblastoma Splenomegaly Infections: Malaria, infective Kala-azar, chronic malaria, infective endocarditis, enteric fever endocarditis Malignancy: Acute leukemia Chronic myeloid leukemia, non- Hodgkin lymphoma Hepatosplenomegaly Infections: Malaria, enteric fever, Tuberculosis, kala-azar, brucellosis, infectious mononucleosis, infectious mononucleosis rickettsial co-infections Malignancy: Acute leukemia Acute leukemia, lymphoma, histiocytosis Connective tissue diseases SLE, JIA Lymphadenopathy Suppurative lymphadenitis, Tuberculosis, HIV, lymphoma, ALL, Kawasaki disease systemic onset JIA Hepatosplenomegaly Malignant disorders of Tuberculosis, HIV, lymphoma, ALL with lymphadenopathy reticuloendothelial system Rash Infections: Dengue, measles, Lupus vulgaris varicella, meningococcemia Connective tissue diseases/vasculitis: Systemic onset JIA, SLE Kawasaki disease, Henoch-Schonlein purpura (HSP) Arthritis Septic arthritis, Kawasaki disease, Juvenile idiopathic arthritis, SLE, acute HSP, rheumatic fever, chikungunya rheumatic fever, dermatomyositis, polymyositis, reactive arthritis, tubercular arthritis mebooksfree.com  Clinical Methods in Pediatrics 16.2 CHILD WITH LOOSE STOOLS 0 Symptoms suggestive of some dehydration: Increased thirst, irritability, passing lesser A. Definitions amount of urine Diarrhea: Increase in frequency and change in 0 Symptoms suggestive of severe dehydration: consistency of stools, i.e. passage of liquid or Lethargy, decreased oral acceptance and not watery stools more than three times a day. passing urine Dysentery: Loose stools with blood. 0 Symptoms suggesting dyselectrolytemia: Seizures, altered sensorium, abdominal Persistent diarrhea: Loose stools for >14 days, distension usually infective in origin. 0 Symptoms suggesting systernic involvement: Chronic diarrhea: Loose stools >14 days, High grade fever, altered sensorium, pain usually non-infective, may be due to abdomen, persistent vomiting, cough, malabsorption. It is usually associated with urinary complaints, necl< rigidity failure to thrive. C.Clinical Scenarios and B. History Taking Differential Diagnosis Elicit the history of following symptoms in a Table 16.11 presents several different clinical child with suspected diarrheal illness: scenarios in a child with loose stools, to 0 Duration (to differentiate between acute differentiate between acute watery diarrhea, watery diarrhea and persistent diarrhea) dysentery, cholera, persistent diarrhea, chronic 0 Consistency and frequency of stools (rice diarrhea, etc. based on the history of presenting watery stools suggest cholera) illness. Causes of common complications 0 Presence of blood in stools (to differentiate (seizures, altered sensorium, abdominal between diarrhea and dysentery) distension, etc.) are also discussed. Table 16.11 Approach to clinical and etiological diagnosis ofa child with loose stools, based on presenting illness Chief complaint Associated Probable diagnosis Explanation and etiology complaints Loose, watery stools, Non-bilious, non- Acute watery diarrhea 0 Loose watery stools >3 times/ 8—1 0 times/day x projectile vomiting, day, without blood suggests 3 days 1—2 episodes acute diarrhea. 0 Rotavirus is the most common cause followed by entero- toxigenic E. coli Loose stools with No specific Acute watery diarrhea 0 Presence of mucus does not mucus, 5—8 times/day associations always indicate dysentery x 4 days with fever 0 Fever also may not always indicate a systemic involve- ment. It can be a part of acute diarrheal illness Loose, watery stools Ask for rice watery Cholera Vibrio cholerae 20—25 times per day character of stools, x 1—2 days especially in children >2 years (Contd.) mebooksfree.com  Clinical Approach to Common Cases Table 16.11 Approach to clinical and etiological diagnosis ofa child with loose stools, based on presenting illness (Contd...) Chief complaint Associated Probable diagnosis Explanation and etiology complaints Loose stools with May be associated Dysentery 0 Gross blood in stools is the most blood, 5—6 times/day with cramps or pain reliable sign of dysentery. x 3 days abdomen 0 Most common organisms: Shige/la, E.coli 0 E. histolytica is not a common cause. Loose stools 6—8 No past history of Persistent diarrhea 0 Acute diarrhea persisting for times/day x 75 days loose stools for more than 14 days is known as > 14 days. persistent diarrhea. Starts as an episode 0 More common in malnourished of acute watery children and children < 2 years diarrhea. Loose, semi-formed Stools are bulky, Chronic diarrhea Diarrhea with "abnormal stools" stools, 4—5 times/day frothy and sticky. which continue or recur over x 2 months on and off There is intermittent several months. abdominal distension Malabsorption disorders are the especially after meals. most common cause. Usually associated with failure to thrive and anemia Loose stools with History of giving Acute diarrhea with Hyponatremia altered sensorium ORS in inappropriate dyselectrolytemia Hypernatremia dilution. Hypoglycemia History of persistent Encephalopathy Enteroviral diarrhea, Shige/la vomiting OR encephalopathy Viral encephalitis Loose stools with High grade fever Febrile seizure There may be co-existi ng systemic seizures infection Altered sensorium Hyponatremia Serum sodium 150 mEq/L, Hypoglycemia Blood sugar