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History
On the basis of the chief complaint, the pediatrician must ask question that help distinguish between common and potentially life threatening entities.
Common complaints
Vomiting
Respiratory distress Fever Abdominal pain
Feeding changes
Lethargic in febrile patients must be differentiated from lethargic child with sepsis or meningitis Child w/ sepsis or meningitis:
Seizures
Decreased urine output
Patiens w/ poisoning or inborn error metabolism can also be present with lethargy, poor feeding, seizure and vomiting.
History of fever
Complaints of neck pain Photophobia vomiting
Ataxia
Slurred speech Seizures
vomiting
Vomiting is a very common complaint of intestinal, abdominal (pancreas,liver) or non-GI (hyperammonemia, increased intracranial pressure)
Care should be taken to determine whether the emesis is bilious => suggestive of intestinal obstruction
Weight changes
Presence of diarrhea Obstipation or hematochezia History of trauma Presence of headache
Common causes of vomiting are gastroesophageal reflux and viral gastroenteritis In infant, bilious emesis and abdominal distention and/or pain are worrisome for obstruction. Important to consider extra-abdominal causes in neonate e.g: hydrochepalus, incarcerated hernia, inborn errors of metabolism, nonaccidental trauma
Diabetic ketoacidosis
Appendicitis Poisonings
Trauma
Patient w/ headache and vomiting, concern for increased intracranial pressure and should be questioned about neurologic changes, meningismus and fever
Respiratory distress
Normal variations in respiratory patterns must be distinguished from true respiratory distress Ask about associated symptoms such as fever, limitation of neck movement, drooling, choking, stridor ,or wheezing History of apnea or cyanosis warrants further investigation
Infants with congenital heart defects may be tachypneic but may lack any signs of resp.distress. In older children with wheezing after coughing or choking episode must be evaluated for a foreign body aspiration. Stridor is most commonly due to croup
Epiglotitis
Bacterial tracheitis Rapidly expanding retropharyngeal abscess (may present with drooling, limitation of neck movement (esp. hyerextension)
Fever
Most fevers are the result of self limited viral infections In first 3 months, pathogens that can cause sepsis:
Group B streptococcus
E. coli Listeria monocytogenes Herpes simplex virus
In neonates, history mus include obstetric information and patient's birth history Septic infant can present w/:
Lethargy
Poor feeding
Grunting respirations Impaired perfusion fever
Streptococcus penumoniae
H.influenzae type B Neisseria meningitidis
Septic arthritis (only one joint, painful and often w/ pseudoparalysis of that joint) Osteomyelitis Juvenile rheumatiod arthritis (pain, stiffness, swelling, warmth in several joints) Kawasaki disease
Abdominal pain
Ask about: stooling patterns, abdominal distention, fever, urinary symptoms, vomiting.
In neonates,appear ill and tender abdomen is concerning for presence of small bowel obstruction. There may be history of vomiting and decreased or no stooling
Bloody stools can also present in milk protein intolerance but these infants are well appearing and no abdominal tenderness
Diagnosis of appendicitis in the child younger than 3 years is difficult because they do not localize their pain well. Diagnosis is often made after the appendix has ruptured.