Pediatric emergency medicine trisk 0536 0536
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A complete physical examination is essential for determining the severity of
the dehydration in the child with diarrheal illness as well as for determination of
potential etiologies for the diarrhea (see Chapters 22 Dehydration and 100 Renal
and Electrolyte Emergencies ). Various clinical scales have been developed and
validated to determine the degree of dehydration. Scales that are commonly used
in the acute care setting include the Gorelick scale, the Clinical Dehydration
Scale (CDS), and the World Health Organization (WHO) scale. See Figure 23.2
for these scales.
Altered mental status may be seen in children with severe dehydration,
hypovolemic shock, and intussusception. Pallor and petechiae may denote HUS
or malignancy. On abdominal examination, the findings of a mass (IBD,
intussusception, malignancy) or evidence of obstruction (abdominal distention,
pain, and paucity of bowel sounds) is important. A rectal examination should be
performed in the child who has chronic diarrhea. With overflow stools secondary
to prolonged constipation, the rectal ampulla often contains a large amount of
hard stool, but it is usually empty in the patient with Hirschsprung disease.
Routine diagnostic testing is not necessary in pediatric patients with suspected
self-limiting diarrheal disease. Patients with fever, bloody diarrhea, mucoid
stools, severe abdominal pain, and/or signs of sepsis should have stool samples
evaluated for bacterial and other pathogens. Blood cultures are indicated for ill or
toxic-appearing patients of any age with diarrhea, children under 3 months,
immunocompromised hosts, and those being evaluated for fever of unknown
origin who have traveled to or had contact with travelers from enteric fever
endemic areas. If a history of significant stool output accompanied by poor oral
intake is obtained, bedside point of care glucose check should be performed to
evaluate for possible hypoglycemia, especially in infants and toddlers.
Electrolytes, BUN, and creatinine should be obtained only if the history and/or
physical examination are concerning for potential electrolyte abnormalities or
impaired renal function. Plain abdominal films should be performed in patients
with suspected gastrointestinal obstruction but are frequently normal in children
with intussusception and gastroenteritis. Because of its high diagnostic sensitivity
and lack of ionizing radiation, ultrasound (US) has replaced contrast enema as the
diagnostic test of choice in children with suspected intussusception. US may also
be helpful in the diagnosis of the patient with appendicitis. When HUS is
suspected, a complete blood count, renal function studies including serum
creatinine, urinalysis, coagulation studies, and peripheral smear should be
performed. The peripheral blood smear, in addition to reduced numbers of
platelets, may show evidence of intravascular hemolysis, including helmet cells
