Pediatric emergency medicine trisk 0654 0654
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simply have a less serious viral infection or streptococcal pharyngitis.
Differentiation of these entities is crucial and is based on clinical appearance of
the patient and laboratory evaluation. A child with only a few petechiae
(especially if only above the nipple line), normal white blood cell (WBC) count,
normal platelet count, and well appearance is less likely to have invasive disease.
However, any child who appears ill, has distinctly abnormal laboratory results, or
has a rapidly progressive petechial rash needs a more complete evaluation for
sepsis or meningitis and should receive empiric antibiotics. A patient with fever
and diffuse erythroderma should be evaluated carefully for hemodynamic
instability or other signs and symptoms of toxic shock syndrome. Fever
associated in a young child with severe skin blistering and exfoliation may be
toxin-mediated staphylococcal-scalded skin syndrome.
On physical examination, acute otitis media is identified by the acute onset of
otalgia or fever with changes in the tympanic membranes, such as redness,
bulging, decreased mobility, loss of landmarks and light reflex, air–fluid level
behind the tympanic membrane, or purulent drainage from a perforation. Careful
examination of the head and neck may reveal rhinorrhea and signs of
inflammation, suggesting a viral upper respiratory infection (URI). The
oropharynx may reveal pharyngitis or stomatitis (see Chapters 52 Oral Lesions
and 74 Sore Throat ). Children with a history of a recent respiratory infection may
have reactive, tender, swollen cervical lymph nodes; asymmetric enlargement of
nodes, especially with tenderness and overlying erythema, might indicate
bacterial lymphadenitis. Croup is readily identified by a barky cough with or
without stridor in young children, whereas a distinctive “hot potato voice” with
unilateral tonsillar swelling in adolescents indicates a peritonsillar abscess.
Wheezing, tachypnea, and fever in infants younger than 2 years of age usually
mark bronchiolitis. Pneumonia often presents with cough, fever, tachypnea,
auscultatory
findings,
and
hypoxemia.
Wheezing/rales,
tachypnea,
disproportionate tachycardia, poor perfusion, and hepatomegaly, with or without
chest pain, may indicate myocarditis. Mild abdominal pain or tenderness,
vomiting, and/or diarrhea most often suggest viral gastroenteritis but early
hepatitis, appendicitis, or pancreatitis should also be considered. More severe
findings, particularly the occurrence of peritoneal signs, may indicate
appendicitis, intra-abdominal abscess, or peritonitis from other causes (see
Chapters 53 Pain: Abdomen , 91 Gastrointestinal Emergencies , and 92
Gynecology Emergencies ) However, in children, fever with abdominal pain may
also represent lower lobe pneumonia, streptococcal pharyngitis, urinary tract
infection (UTI), gastroenteritis, or mesenteric adenitis. Additional findings in UTI
