Professional Documents
Culture Documents
The Acutely Ill Child: Evaluation of The Sick Child in The Office and Clinic
The Acutely Ill Child: Evaluation of The Sick Child in The Office and Clinic
The Acutely Ill Child: Evaluation of The Sick Child in The Office and Clinic
474
Downloaded for FKIK Universitas Muhammadiyah Yogyakarta (fkik1.ck@gmail.com) at Universitas Muhammadiyah Yogyakarta from ClinicalKey.com by Elsevier on March 09, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Chapter 65 ◆ Evaluation of the Sick Child in the Office and Clinic 475
A history of apnea or cyanosis warrants further investigation. Although fever, and the presence of tachypnea and hypotension all suggest a
wheezing is often secondary to bronchospasm, it can also be caused by serious infection. The respiratory evaluation includes determining
cardiac disease or congenital anomalies such as vascular rings. Infants respiratory rate, the presence or absence of hypoxia by pulse oximetry,
with congenital heart defects may be tachypneic but may lack any signs and noting any evidence of inspiratory stridor, expiratory wheezing,
of respiratory distress as a compensatory mechanism for shock or grunting, coughing, or increased work of breathing (e.g., retractions,
metabolic acidosis. Parents often confuse and interpret stridor as nasal flaring, belly breathing). Because acute infections in children are
wheezing, and care should be taken to differentiate the two. Stridor is most often caused by viral infections, the presence of nasal discharge
most commonly caused by croup. However, anatomic abnormalities may be noted. It is possible at this time to assess the skin for rashes.
such as laryngeal webs, laryngomalacia, subglottic stenosis, and para- Frequently, viral infections cause an exanthem and many of these erup-
lyzed vocal cords also cause stridor. Toddlers who present with wheez- tions are diagnostic (e.g., the reticulated rash and “slapped-cheek”
ing or stridor after a coughing or choking episode should be evaluated appearance of parvovirus infections or the typical appearance of hand-
for a foreign body aspiration. In toxic-appearing children with stridor, foot-and-mouth disease caused by coxsackieviruses). The skin exami-
the pediatrician should consider epiglottitis, bacterial tracheitis, or a nation may also yield evidence of more serious infections (bacterial
rapidly expanding retropharyngeal abscess. The incidence of epiglot- cellulitis or petechiae and purpura associated with bacteremia). Cuta-
titis has markedly declined with the advent of the H. influenzae type b neous perfusion should be assessed by warmth and capillary refill time.
(Hib) vaccine, but remains a possibility in the unimmunized or par- When the child is seated and is least perturbed, an assessment of the
tially immunized patient. Children with retropharyngeal abscesses fontanel can be completed; the examiner can determine whether the
may also present with drooling and limitation of neck movement fontanel is depressed, flat, or bulging.
(especially hyperextension) after a recent upper respiratory infection During this initial portion of the physical examination, when the
or penetrating mouth injury. child is most comfortable, the heart and lungs are auscultated. In the
Abdominal pain is another frequent complaint. Often this symptom acutely febrile child, because of the relatively frequent occurrence of
is caused by a minor illness such as constipation, functional abdominal respiratory illnesses, it is important to assess adequacy of air entry into
pain, urinary tract infection, or gastroenteritis. Parents should be ques- the lungs, equality of breath sounds, and evidence of adventitial breath
tioned about associated symptoms including stooling patterns, abdom- sounds, especially wheezes, rales, and rhonchi. The coarse sound of air
inal distention, fever, urinary symptoms, and vomiting. In neonates, a moving through a congested nasal passage is frequently transmitted to
tender abdomen is concerning for the presence of a small bowel the lungs. The examiner can become attuned to these coarse sounds
obstruction; these infants tend to appear ill. There may be a history of by placing the stethoscope near the child’s nose and then compensating
vomiting and decreased or no stooling. Pediatricians should be wary for this sound as the chest is auscultated. The cardiac examination is
of neonates with abdominal tenderness and bloody stools, as 10% of next; findings such as pericardial friction rub, loud murmurs, and
cases of necrotizing enterocolitis occur in term infants. Infants with distant heart sounds may indicate an infectious process involving the
milk protein intolerance can also present with bloody stools, but these heart. The eyes are examined to identify features that might indicate
infants are well-appearing and do not have abdominal tenderness. In an infectious process. Often, viral infections result in a watery dis-
older patients, the differential diagnosis for a potential emergency with charge or redness of the bulbar conjunctivae. Bacterial infection, if
abdominal pain expands to include intussusception and appendicitis. superficial, results in purulent drainage; if the infection is more deep-
Patients with intussusception can present in a variety of ways, ranging seated, tenderness, swelling, and redness of the tissues surrounding the
from having episodes of colicky abdominal pain, but otherwise well in eye are present, as well as proptosis, reduced visual acuity, and altered
between episodes, to being lethargic or in shock. The diagnosis of extraocular movement. The extremities may then be evaluated not only
appendicitis in the child younger than 3 yr is extremely difficult for ease of movement but also for the possibility of swelling, heat, or
because children in this age group do not localize their pain well. Often tenderness; such abnormalities may indicate focal infections.
the diagnosis is made after the appendix has ruptured. The components of the physical examination that are more bother-
The child’s past medical history also needs to be obtained. It is some to the child are completed last. This is best done with the patient
important to be aware of any underlying chronic problems that might on the examination table. Initially, the neck is examined to assess for
predispose the child to recurring infections or a serious acute illness. areas of swelling, redness, or tenderness, as may be seen in cervical
The child with sickle cell anemia is at increased risk for bacteremia, as adenitis. Resistance to neck movement should prompt evaluation for
well as painful vasoocclusive crisis. A careful review of systems can signs of meningeal irritation (i.e., Kernig and Brudzinski signs) or a
help in identifying the nature of the acute illness, as well as any com- retropharyngeal abscess. During examination of the abdomen, the
plications needing intervention, such as dehydration accompanying an diaper is removed. The abdomen is inspected for distention. Ausculta-
otherwise minor viral illness. tion is performed to assess adequacy of bowel sounds, followed by
palpation. The child often fusses as the abdomen is auscultated and
PHYSICAL EXAM palpated. Every attempt should be made to quiet the child; if this is not
Observation is important in the evaluation of the acutely ill child. possible, increased fussing as the abdomen is palpated may indicate
Most observational data that the pediatrician gathers during an acute tenderness, especially if this finding is reproducible. In addition to
illness should focus on assessing the child’s response to stimuli. Do focal tenderness, palpation may elicit involuntary guarding or rebound
they awaken easily with a stimulus? Do they smile and interact with tenderness (including tenderness to percussion); these findings indi-
the examiner? Can the crying child be consoled by the parents’ com- cate peritoneal irritation, as is seen in appendicitis. The inguinal area
forting? Assessing responses to stimuli requires knowledge of normal and genitals are then sequentially examined. The child is then placed
responses for different age groups, the manner in which those normal in the prone position, and abnormalities of the back are sought. The
responses are elicited, and to what degree a response might be impaired. spine and costovertebral angle areas are percussed to elicit any tender-
Thus, the pediatrician must be both clinically and developmentally ness; such a finding may be indicative of vertebral osteomyelitis or
oriented. diskitis and pyelonephritis, respectively.
During the physical examination, the pediatrician seeks evidence Examining the ears and throat completes the physical examination.
of illness. The portions of the physical examination that require the These are usually the most bothersome parts of the examination for
child to be most cooperative are completed first. Initially, it is best to the child, and parents frequently can be helpful in minimizing head
seat the child on the parent’s lap; the older child may be seated on the movement. During the oropharyngeal examination, it is important to
examination table. It is also important to assess the child’s willingness document the presence of enanthemas; these may be seen in many
to move and ease of movement. It is reassuring to see the child moving infectious processes, such as hand-foot-and-mouth disease caused by
about on the parent’s lap with ease and without discomfort. Vital signs coxsackievirus. This portion of the examination is also important in
are often overlooked but are invaluable in assessing ill children. The documenting inflammation or exudates on the tonsils, which may be
degree of fever, the presence of tachycardia out of proportion to the viral or bacterial.
Downloaded for FKIK Universitas Muhammadiyah Yogyakarta (fkik1.ck@gmail.com) at Universitas Muhammadiyah Yogyakarta from ClinicalKey.com by Elsevier on March 09, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
476 Part IX ◆ The Acutely Ill Child
Repeating portions of the assessment may be indicated. If the child necessary in patients in whom airway patency cannot be maintained.
cried continuously during the initial clinical evaluation, the examiner These devices are not well-tolerated in conscious patients and may
may not be certain whether the crying was caused by the high fever, induce gagging or vomiting, and instead are most often utilized to
stranger anxiety, or pain, or is indicative of a serious or localizing facilitate effective bag-valve-mask ventilation. Once airway patency has
illness. Constant crying also makes portions of the physical examina- been established, the adequacy of breathing should be evaluated. Slow
tion, such as auscultation of the chest, more difficult. Before a repeat respiratory rates or cyanosis may signal respiratory failure. If the
assessment is performed, efforts to make the child as comfortable as airway is patent but the child’s respiratory effort is inadequate, positive
possible are indicated. pressure ventilation via bag-valve-mask should be initiated. Oxygen
Febrile children can appear very ill, initially appearing listless, tachy- should be administered to all seriously ill or hypoxic children via nasal
cardic, and tachypneic. These patients should receive antipyretic medi- cannula or face mask. Auscultation of the lung fields should assess for
cations and be reassessed once they have defervesced. In the majority air entry, symmetry of breath sounds, and presence of adventitious
of children with uncomplicated viral illnesses, the vital signs normal- breath sounds such as crackles or wheezes. Bronchodilator therapy can
ize. Persistence of abnormal vital signs should prompt the clinician to be initiated to alleviate bronchospasm. Racemic epinephrine is indi-
further investigate the source of fever. Continued tachycardia and poor cated for stridor at rest in a patient with croup. Once airway and
perfusion may be secondary to myocarditis. Tachypnea may be the sole breathing have been addressed, circulation must be evaluated. This
symptom in patients with pneumonia, especially in children whose involves assessment of cardiac output. Symptoms of shock include
chief complaint is abdominal pain due to lower lobe pneumonia. Per- tachycardia, cool extremities, delayed capillary refill time, mottled or
sistent irritability suggests meningitis/encephalitis. pale skin, and effortless tachypnea. Hypotension is a late finding in
shock and indicates significant decompensation has already taken place.
RISK FACTORS Vascular access is necessary for volume resuscitation in patients with
The sensitivity of the carefully performed clinical assessment, observa- impaired circulation, and an intraosseous line should be considered
tion, history, and physical examination for the presence of serious early on if there is any difficulty in vascular access for a patient requir-
illness is approximately 90%. If a serious illness is suspected, other data ing resuscitation. Once an intervention is performed, the clinician
should be sought to improve this sensitivity level. Important supple- must reassess the patient.
mental data are age, body temperature, and the results of screening If the febrile child is older than 3 mo and appears well, if the history
laboratory tests as indicated. Febrile children in the first 3 mo of life or physical examination does not suggest a serious illness, the child
have yet to achieve immunologic maturity and therefore are more may be followed expectantly. This profile applies to most children with
susceptible to severe infections. Thus, the febrile infant is at greater risk acute febrile illnesses. If, on the other hand, the child appears ill, or the
for serious bacterial infection than the child beyond 3 mo of age and history or physical examination suggests a serious infection, definitive
warrants careful evaluation. Data from the era before widespread laboratory tests appropriate for those findings are indicated (chest
immunization for H. influenzae type b and pneumococcus suggest the x-ray for a child with grunting). If advanced imaging is required (ultra-
risk of bacteremia in infants increases as the magnitude of fever sound or CT scan for suspected appendicitis), it may be prudent to
increases; it is unclear how this applies today. defer such testing to pediatric specialty care if the decision has already
Screening laboratory tests may be helpful in identifying the febrile been made to transport the child to a higher level of care. The area of
child at increased risk for selected serious illnesses. Practice guidelines greatest controversy is whether laboratory studies are needed in a
from the prevaccine era suggested that white blood cell count might febrile child who appears well and has no abnormalities on history and
be useful in establishing a higher risk of bacteremia. Because the inci- physical examination, but who is younger than 3 mo or whose tem-
dence of occult pneumococcal bacteremia in febrile children has perature is high. Many would agree that a sepsis work-up is indicated
declined significantly as a result of the introduction of conjugated in the febrile child younger than 1 mo and possibly in the febrile child
pneumococcal vaccine, the utility of white blood cell count in other- who is as old as 3 mo.
wise healthy febrile young children older than 2-3 mo of age is ques-
tionable. Urinalysis and urine culture must always be considered when DISPOSITION
the source of fever is not apparent, especially in the highest-risk groups: The majority of children evaluated in the office for an acute illness can
females and uncircumcised males younger than 2 yr of age and all boys be managed on an outpatient basis. These patients should have reas-
younger than 1 yr of age. The presence of leukocyte esterase, >5 white suring physical examinations, stable vital signs, and adequate follow-up.
blood cells/high-power field on a spun urine specimen, or bacteria A mildly dehydrated patient can be discharged to home for a trial of
detected by Gram stain on an unspun urine specimen suggests urinary oral rehydration. Patients with a respiratory illness who are exhibiting
tract infection, but the sensitivity of these indicators is, on average, only signs of mild respiratory distress may be monitored at home with a
75-85%; urine culture is the definitive test. Procalcitonin, C-reactive repeat examination scheduled for the next day. Depending on the
protein, and interleukin-6 are being investigated as potential biomark- child’s status, the comfort of the parents, and the relationship of the
ers of differentiating serious bacterial illness from benign viral disease family with the physician, telephone follow-up may be all that is
in children. necessary.
If the physician feels comfortable in following as an outpatient the
MANAGEMENT child in whom no specific diagnosis has been established, a follow-up
Most patients who present to the pediatrician’s office with an acute examination may yield the diagnosis. During the initial visit, or from
illness will not require resuscitation. However, the pediatrician needs one visit to the next during the acute illness, the change in symptoms
to be prepared to evaluate and begin resuscitation for the seriously ill or in the findings on physical examination over time may provide
or unstable child. The pediatrician’s office should be stocked with important diagnostic clues. For the child in whom a diagnosis has
appropriate equipment necessary to stabilize an acutely ill child. Main- already been established and who does not require hospitalization,
tenance of that equipment and ongoing training of the office staff in follow-up by telephone or an office visit should be used to monitor the
use of the equipment and procedures is required (see Chapter 66). The course of the illness and to further educate and support the parents.
evaluation must begin with assessment of the ABCs—airway, breath- However, if it is deemed that the child needs a higher level of care,
ing, and circulation. When assessing the airway, chest rise should be it is the pediatrician’s responsibility to decide what method of transfer
evaluated, and evidence of increased work of breathing sought. The is appropriate. Physicians may be reluctant to call for help because of
examiner should ensure that the trachea is midline. If the airway is a misperception that 911 services should be activated only for full-
patent and no signs of airway obstruction are present, the patient is blown resuscitations. Emergency Medical Services (EMS) transport
allowed to assume a position of comfort. If the child shows signs of should be initiated for any child who is physiologically unstable (e.g.,
airway obstruction, repositioning of the head with the chin-lift maneu- with severe respiratory distress, hypoxia, signs of shock, or altered
ver may alleviate the obstruction. An oral or nasal airway may be mental status). If the family’s ability to comply promptly with
Downloaded for FKIK Universitas Muhammadiyah Yogyakarta (fkik1.ck@gmail.com) at Universitas Muhammadiyah Yogyakarta from ClinicalKey.com by Elsevier on March 09, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
recommendation for emergency department evaluation is in question,
that patient should also be transported by EMS. Some physicians and
families may defer calling EMS because of the perception that a parent
can get to the hospital faster by private car. Although rapidity of trans-
port should be considered, the need for further interventions during
transport and the risk of clinical decompensation are other important
factors in the decision to activate EMS. Ultimately, the legal responsi-
bility for choosing an appropriate level of transport for a patient lies
with the referring physician, until responsibility of care is officially
transferred to another medical provider.
Downloaded for FKIK Universitas Muhammadiyah Yogyakarta (fkik1.ck@gmail.com) at Universitas Muhammadiyah Yogyakarta from ClinicalKey.com by Elsevier on March 09, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Chapter 65 ◆ Evaluation of the Sick Child in the Office and Clinic 477.e1
Bibliography Kleinman ME, Chameides L, Schexnayder SM, et al: Part 14: pediatric advanced
Avner JR, Baker MD: Occult bacteremia in the post-pneumococcal conjugate life support: 2010 American Heart Association Guidelines for Cardiopulmonary
vaccine era: does the blood culture stop here? Acad Emerg Med 16(3):258–260, Resuscitation and Emergency Cardiovascular Care, Circulation 122(18 Suppl 3):
2009. S876–S908, 2010.
Berg MD, Schexnayder SM, Chameides L, et al: Part 13: pediatric basic life Klig JE, O’Malley PJ: Pediatric office emergencies, Curr Opin Pediatr 19:591–596,
support: 2010 American Heart Association Guidelines for Cardiopulmonary 2007.
Resuscitation and Emergency Cardiovascular Care, Circulation 122(18 Suppl 3): Marin JR, Alpern ER: Abdominal pain in children, Emerg Med Clin North Am
S862–S875, 2010. 29(2):401–428, 2011.
Choi J, Lee GL: Common pediatric respiratory emergencies, Emerg Med Clin North Wilkinson M, Bulloch B, Smith M: Prevalence of occult bacteremia in children
Am 30(2):529–563, 2012. aged 3 to 36 months presenting to the emergency department with fever in
Hamilton JL, John SP: Evaluation of fever in infants and young children, Am Fam the postpneumococcal conjugate vaccine era, Acad Emerg Med 16(3):220–225,
Physician 87(4):254–260, 2013. 2009.
Jhaveri R, Byington CL, Klein JO, et al: Management of the non-toxic-appearing
acutely febrile child: a 21st century approach, J Pediatr 159(2):181–185, 2011.
Downloaded for FKIK Universitas Muhammadiyah Yogyakarta (fkik1.ck@gmail.com) at Universitas Muhammadiyah Yogyakarta from ClinicalKey.com by Elsevier on March 09, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.