Schwartz's Clinical Handbook of Pediatrics

(1)

(2)

(3)

(4)

Clinical Handbook

of Pediatrics

S c h w a r t z ’ s

F I F T H E D I T I O N

(5)

(6)

Clinical Handbook

of Pediatrics

S c h w a r t z ’ s

F I F T H E D I T I O N

E D I T O R

Joseph J. Zorc

A S S O C I A T E E D I T O R S

Elizabeth R. Alpern

Lawrence W. Brown

Kathleen M. Loomes

Bradley S. Marino

Cynthia J. Mollen

Leslie J. Raffi ni

(7)

Product Manager: Stacey Sebring Marketing Manager: Joy Fisher-Williams Designer: Teresa Mallon

Compositor: Aptara, Inc.

Fifth Edition

351 West Camden Street Two Commerce Square

Baltimore, MD 21201 2001 Market Street

Philadelphia, PA 19103

Printed in

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their offi cial duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via website at lww.com (products and services).

9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data Schwartz’s clinical handbook of pediatrics / editor, Joseph J. Zorc ; associate editors, Elizabeth R. Alpern ... [et al.]. – 5th ed.

p. ; cm.

Clinical handbook of pediatrics

Includes bibliographical references and index.

ISBN 978-1-60831-578-9 (alk. paper)

I. Zorc, Joseph J. II. Alpern, Elizabeth R. III. Schwartz, M. William, 1935- IV. Title: Clinical handbook of pediatrics.

[DNLM: 1. Pediatrics–Handbooks. WS 39]

618.92–dc23

2011050194

DISCLAIMER

Care has been taken to confi rm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Applica- tion of this information in a particular situation remains the professional responsibility of the practitioner;

the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant fl ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.

To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300.

Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams &

Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.

(8)

JJZ

To Judi, Robbie, Michael, Julia, and Sarah ERA

With love and thanks to Michael, Ava, and Talia LB

To Naomi and the next generation of pediatricians KL

To my mother Joan BM

To Judi, Max, and Zachary CM

To Thom, Anna, Claire and my parents, Bill and Janet Johnson

LR

To Frank and Hannah

(9)

or this fi fth edition of the Clinical Handbook of Pediatrics, we have continued the pragmatic approach to assessment, differential diagnosis, and management of pediatric illness envisioned by Dr. M. William Schwartz in creating this text. We have also responded to recommendations from readers to continue to streamline and reduce the size of the book to make it easier to bring it to the bedside. I hope we have succeeded in these goals and look forward to receiv- ing suggestions for the design of future editions.

Special thanks go to the associate editors, Elizabeth Alpern, Larry Brown, Kathy Loomes, Brad Marino, Cynthia Mollen, and Leslie Raffi ni, who worked closely with the authors and added much to the quality of this text. My thanks go to all of the authors who updated the evidence in their area and often brought on junior colleagues to add a fresh perspective. I would also like to thank the team at Lippincott/Wolters Kluwer, including Steve Boehm and Stacey Sebring. A book such as this resembles a quilt representing the efforts of many individuals, and I hope that we have successfully woven it together into a whole that will benefi t the clinicians and the children for whom it was intended.

F

P R E F A C E

(10)

vii

C O N T R I B U T O R S

Nicholas S. Abend, MD Assistant Professor of Neurology and

Pediatrics

University of Pennsylvania School of Medicine

Philadelphia, PA Attending Neurologist

Children’s Hospital of Philadelphia Philadelphia, PA

Elizabeth R. Alpern, MD, MSCE Associate Professor

Department of Pediatrics Perelman School of Medicine University of Pennsylvania Philadelphia, PA

Director of Research, Attending Physician Division of Emergency Medicine Children’s Hospital of Philadelphia Philadelphia, PA

Craig Alter, MD

Associate Professor of Clinical Pediatrics Department of Pediatrics

University of Pennsylvania Philadelphia, PA Fellowship Director Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Jeffrey Anderson, MD, MPH Assistant Professor of Pediatrics Department of Pediatrics University of Cincinnati Cincinnati, OH Electro Physiologist Heart Institute

Cincinnati Children’s Hospital Medical Center

Cincinnati, OH

Paul L. Aronson, MD Instructor

Department of Pediatrics

Philadelphia, PA Fellow

Division of Pediatric Emergency Medicine

Oluwakemi B. Badaki-Makun, MD, CM

Assistant Professor

Pediatrics and Emergency Medicine George Washington University Washington, DC

Attending Physician

Emergency Medicine and Trauma Services

Children’s National Medical Center Washington, DC, 20010 Fran Balamuth, MD, PhD Lecturer

Department of Pediatrics University of Pennsylvania School

of Medicine Philadelphia, PA Fellow

Department of Pediatrics Division of Emergency

Medicine

(11)

Christina Bales, MD

Assistant Professor of Clinical Medicine Department of Pediatrics

Perelman School of Medicine University of Pennsylvania Philadelphia, PA Attending Physician Department of Pediatrics

Division of Gastroenterology, Hepatology, and Nutrition

Andrew J. Bauer, MD Associate Professor Department of Pediatrics Uniformed Services University Bethesda, MD

Senior Consultant The Thyroid Center Department of Endocrinology Children’s Hospital of Philadelphia Philadelphia, PA

Suzanne E. Beck, MD

Associate Professor of Clinical Pediatrics Department of Pediatrics

University of Pennsylvania Philadelphia, PA

Attending Pediatric Pulmonologist and Sleep Medicine Specialist

Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Mercedes M. Blackstone, MD Assistant Professor of Clinical Pediatrics Department of Pediatrics

Philadelphia, PA Attending Physician

Division of Emergency Medicine Children’s Hospital of Philadelphia Philadelphia, PA

Lawrence W. Brown, MD Associate Professor

Departments of Neurology and Pediatrics University of Pennsylvania School of

Medicine Philadelphia, PA

Director, Pediatric Neuropsychiatry Division of Neurology

Diane P. Calello, MD Staff Toxicologist

Department of Preventive Medicine NJ Poison Information and Education

System

University of Medicine and Dentistry, New Jersey

Newark, NJ Faculty

Pediatric Emergency Medicine Morristown Medical Center Morristown, NJ

Leslie Castelo-Soccio, MD, PhD Assistant Professor

Department of Pediatrics Division of Dermatology Children’s Hospital of Philadelphia Philadelphia, PA

Attending Physician Division of Dermatology Children’s Hospital of Philadelphia Philadelphia, PA

Christine S. Cho, MD, MPH HS Assistant Clinical Professor Department of Pediatrics UCSF School of Medicine San Francisco, CA Attending Physician

Division of Emergency Medicine Children’s Hospital and Research Center

Oakland Oakland, CA

(12)

ix CONTRIBUTORS

Cindy W. Christian, MD Professor

Department of Pediatrics Perelman School of Medicine University of Pennsylvania Philadelphia, PA

Chair, Child Abuse and Neglect Prevention Department of Pediatrics

Esther K. Chung, MD, MPH Associate Professor

Department of Pediatrics Jefferson Medical College Philadelphia, PA Attending Physician Department of Pediatrics

Thomas Jefferson University Hospital Philadelphia, PA

Richard J. Czosek, MD Assistant Professor Pediatric Cardiology

Cincinnati Children’s Hospital Medical Center Cincinnati, OH

Jennifer A. Danzig, MD Instructor

University of Pennsylvania School of Medicine Philadelphia, PA

Fellow

Division of Endocrinology and Diabetes Children’s Hospital of Philadelphia Philadelphia, PA

Katherine MacRae Dell, MD Associate Professor

Department of Pediatrics Case Western Reserve University Cleveland, OH

Chief

Division of Pediatric Nephrology Rainbow Babies and Children’s Hospital Cleveland, OH

Joel A. Fein, MD, MPH

Professor of Pediatrics and Emergency Medicine

Philadelphia, PA Attending Physician Emergency Department

Alexander G. Fiks, MD, MSCE Assistant Professor of Pediatrics Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician

Kristin N. Fiorino, MD Assistant Professor Department of Pediatrics University of Pennsylvania Philadelphia, PA Assistant Professor

Department of Gastroenterology, Hepatology, and Nutrition Children’s Hospital of Philadelphia Philadelphia, PA

Susan A. Friedman, MD Clinical Associate Professor Department of Pediatrics

Philadelphia, PA

Associate Physician, Neonatal Follow-up Program

Medical Director, International Adoption Health Program

Division of Pediatrics

(13)

Marc H. Gorelick, MD, MSCE Professor

Department of Pediatrics Medical College of Wisconsin Milwaukee, WI

Jon E. Vice Endowed Chair Emergency Medicine

Children’s Hospital of Wisconsin Milwaukee, WI

Monika Goyal, MD Assistant Professor Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician

Pediatrics, Division of Emergency Medicine

Adda Grimberg, MD Associate Professor Department of Pediatrics University of Pennsylvania School

of Medicine Philadelphia, PA Scientifi c Director

Diagnostic and Research Growth Center

Toni Gross, MD, MPH Attending Physician Emergency Department Phoenix Children’s Hospital Phoenix, AZ

Andrew Grossman, MD Clinical Assistant Professor Department of Pediatrics Perelman School of Medicine University of Pennsylvania Philadelphia, PA Attending Physician

Andrew N. Hashikawa, MD, MS Clinical Lecturer

Department of Emergency Medicine Section of Children’s Emergency Services University of Michigan

Pediatric Emergency Medicine Emergency Medicine University of Michigan Mott Children’s Hospital Ann Arbor, MI

Timothy M. Hoffman, MD Associate Professor Department of Pediatrics

Ohio State University College of Medicine Columbus, OH

Medical Director

Heart Transplant and Heart Failure Program

The Heart Center

Nationwide Children’s Hospital Columbus, OH

Kan N. Hor, MD

Assistant Professor of Pediatrics Department of Pediatric Cardiology Cincinnati Children’s Hospital Medical

Center Cincinnati, OH

(14)

xi CONTRIBUTORS

Evelyn K. Hsu, MD Assistant Professor Department of Pediatrics

University of Washington Affi liated Hospitals

Seattle, WA

Assistant Professor of Pediatrics Department of Pediatrics

Seattle Children’s Hospital Seattle, WA

Patty Huang, MD Attending Physician

Division of Child Development, Rehabilitation, and Metabolic Disease Children’s Hospital of Philadelphia Philadelphia, PA

Paul Ishimine, MD Associate Clinical Professor

Departments of Emergency Medicine and Pediatrics

University of California, San Diego San Diego, CA

Fellowship Director Pediatric Emergency Medicine Rady Children’s Hospital San Diego, CA

Beth Ann Johnson, MD, MA Assistant Professor

Department of Pediatrics University of Cincinnati Cincinnati, OH Heart Institute

Cincinnati, OH Sara Karjoo, MD Fellow

Pediatric Gastroenterology Children’s Hospital of Philadelphia Philadelphia, PA

Lorraine E. Levitt Katz, MD Associate Professor

Department of Pediatrics University of Pennsylvania School

of Medicine Philadelphia, PA Associate Physician Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Leslie S. Kersun, MD Assistant Professor Department of Pediatrics University of Pennsylvania School

of Medicine Philadelphia, PA Attending Physician Division of Oncology

Timothy K. Knilans, MD Professor

Department of Pediatrics University of Cincinnati College

of Medicine Cincinnati, OH

Director, Cardiac Electrophysiology Heart Institute

Cincinnati, OH Dorit Koren, MD Instructor A

Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician

Division of Endocrinology/Diabetes Philadelphia, PA

(15)

Kate H. Kraft, MD Fellow

Division of Urology

Richard M. Kravitz, MD Associate Professor of Pediatrics Department of Pediatrics

Duke University School of Medicine Durham, NC

Medical Director Pediatric Sleep Laboratory Department of Pediatrics Duke University Medical Center Durham, NC

Christopher J. LaRosa, MD Clinical Assistant Professor Department of Pediatrics Jefferson Medical College Philadelphia, PA Attending Physician Division of Nephrology

A.I. DuPont Hospital for Children Wilmington, DE

Valerie Lewis, MD, MPH Adolescent Medicine Specialist Department of Pediatrics Division of Pediatric Subspecialties

in the Section of Adolescent Medicine

Lehigh Valley Health Network Allentown, PA

Chris A. Liacouras, MD Professor of Pediatrics

Philadelphia, PA

Attending Gastroenterologist

Kathleen M. Loomes, MD Associate Professor Department of Pediatrics

Angela Lorts, MD Assistant Professor Department of Pediatrics University of Cincinnati Cincinnati, OH Cardiac Interventionist Department of Cardiology

Cincinnati, OH

Bradley S. Marino, MD, MPP, MSCE Associate Professor of Pediatrics

University of Cincinnati College of Medicine Cincinnati, OH

Attending Physician

Pediatric Cardiac Intensive Care Department of Pediatrics

Divisions of Cardiology and Critical Care Medicine

Cincinnati, OH

Shoshana T. Melman, MD Associate Professor

University of Medicine and Dentistry of New Jersey/SOM

Stratford, NJ Medical Director Foster Care Program CARES Institute Stratford, NJ

(16)

xiii CONTRIBUTORS

Kevin E. C. Meyers, MD Associate Professor of Pediatrics Department of Pediatrics/Nephrology University of Pennsylvania

Philadelphia, PA Assistant Division Chief

Department of Pediatrics/Nephrology Children’s Hospital of Philadelphia Philadelphia, PA

Okeoma Mmeje, MD, MPH Medical Resident

Department of Obstetrics and Gynecology

Philadelphia, PA Medical Resident

Department of Obstetrics and Gynecology

Hospital of University of Pennsylvania Philadelphia, PA

Cynthia J. Mollen, MD, MSCE Assistant Professor

Department of Pediatrics Perelman School of Medicine University of Pennsylvania Philadelphia, PA Attending Physician

Thomas Mollen, MD Clinical Associate Department of Pediatrics

Philadelphia, PA Associate Medical Director Intensive Care Nursery Pennsylvania Hospital Philadelphia, PA

Amanda Muir, MD Fellow

Department of Gastroenterology, Hepatology, and Nutrition Children’s Hospital of Philadelphia Philadelphia, PA

Frances Nadel, MD, MSCE Associate Professor, Clinical Pediatrics Department of Pediatrics

Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA

Attending Physician

Department of Emergency Medicine Children’s Hospital of Philadelphia Philadelphia, PA

Sara Pentlicky, MD

OBGYN Fellow in Family Practice Department of Obstetrics and Gynecology University of Pennsylvania

Philadelphia, PA

Michael A. Posencheg, MD Assistant Professor of Clinical Pediatrics Division of Neonatology

Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA

Associate Medical Director, Intensive Care Nursery

Medical Director, Newborn Nursery Hospital of the University of Pennsylvania Philadelphia, PA

Jill C. Posner, MD, MSCE Clinical Associate Professor Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician

(17)

Madhura Pradhan, MD

Assistant Professor of Clinical Pediatrics Department of Pediatrics

Perelman School of Medicine University of Pennsylvania Philadelphia, PA Nephrologist

Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Leslie J. Raffi ni, MD, MSCE Assistant Professor

Department of Pediatrics University of Pennsylvania Philadelphia, PA Director

Hemostasis and Thrombosis Center Division of Hematology

Rebecca Ruebner, MD Fellow

Department of Pediatrics Division of Nephrology

Children’s Hospital of Pennsylvania Philadelphia, PA

Andria Barnes Ruth, MD Medical Director

Diabetes Resource Center of Santa Barbara County

Santa Barbara, CA Pediatrician

Santa Barbara Neighborhood Clinics Santa Barbara, CA

Matthew J. Ryan, MD Assistant Professor Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Jack Rychik, MD Professor

Department of Pediatrics University of Pennsylvania Philadelphia, PA Director

Fetal Heart Program

Marta Satin-Smith, MD Assistant Professor Department of Pediatrics Eastern Virginia Medical School Norfolk, VA

Medical Director Diabetes Center Department of Pediatrics

Children’s Hospital of the King’s Daughters Norfolk, VA

Esther M. Sampayo, MD, MPH Assistant Professor

(18)

xv CONTRIBUTORS

Matthew G. Sampson, MD Clinical Instructor

Philadelphia, PA Fellow

Courtney Schreiber, MD, MPH Assistant Professor

Department of Obstetrics and Gynecology University of Pennsylvania

Department of Obstetrics and Gynecology Director

Penn Family Planning and Pregnancy Loss Center

Hospital of the University of Pennsylvania Philadelphia, PA

Jeffrey A. Seiden, MD Assistant Director

Pediatric Emergency Medicine/CARES Virtua Hospital

Voorhees, NJ Kara Shah, MD, PhD Assistant Professor Department of Pediatrics University of Pennsylvania Philadelphia, PA Attending Physician

Department of General Pediatrics, Section of Pediatric Dermatology

The Children’s Hospital of Philadelphia Philadelphia, PA

Samir S. Shah, MD, MSCE Assistant Professor

Department of Pediatrics and Epidemiology University of Pennsylvania School of

Medicine Philadelphia, PA Attending Physician

Divisions of Infectious Diseases and General Pediatrics

Laura N. Sinai, MD, MSCE, FAAP Pediatrician

Department of Pediatrics Gaston Memorial Hospital Gastonia, NC

Kim Smith-Whitley, MD Associate Professor Department of Pediatrics

Philadelphia, PA

Clinical Director of Hematology Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia, PA

Philip R. Spandorfer, MD, MSCE Associate Director of Research

Pediatric Emergency Medicine Associates Atlanta, GA

Attending Physician

Department of Emergency Medicine Children’s Healthcare of Atlanta at Scottish

Rite Atlanta, GA

(19)

Katherine S. Taub, MD Assistant Professor Department of Neurology University of Pennsylvania Philadelphia, PA

Pediatric Epileptologist/Neurologist Department of Neurology Children’s Hospital of Philadelphia Philadelphia, PA

David T. Teachey, MD Assistant Professor Department of Pediatrics University of Pennsylvania School

of Medicine Philadelphia, PA Attending Physician

Pediatric Hematology–Oncology Children’s Hospital of Philadelphia Philadelphia, PA

Lisa K. Tuchman, MD, MPH Assistant Professor

Center for Clinical and Community Research

George Washington University Washington, DC

Faculty

Adolescent and Young Adult Medicine Children’s National Medical Center Washington, DC

René VanDeVoorde III, MD Assistant Professor

Department of Pediatrics University of Cincinnati Cincinnati, OH Medical Director, Dialysis

Pediatric Nephrology and Hypertension Cincinnati Children’s Hospital Medical

Center Cincinnati, OH

Brenda Waber, RD, CSP, CNSD, LDN Neonatal Dietitian

Clinical Nutrition

Stuart A. Weinzimer, MD Associate Professor Department of Pediatrics Yale University New Haven, CT Attending Physician Department of Pediatrics Yale-New Haven Hospital New Haven, CT

Amy L. Weiss, MD, MPH Assistant Professor Department of Pediatrics Division of Adolescent Medicine University of South Florida Tampa, FL

Tampa General Hospital Tampa, FL

Catherine C. Wiley, MD Associate Professor Department of Pediatrics

University of Connecticut School of Medicine

Farmington, CT Chief, General Pediatrics

Connecticut Children’s Medical Center Hartford, CT

James F. Wiley II, MD, MPH Clinical Professor of Pediatrics and

Emergency Medicine/Traumatology University of Connecticut School of

Medicine Farmington, CT Attending Physician Department of Pediatrics

Connecticut Children’s Medical Center Hartford, CT

(20)

xvii CONTRIBUTORS

Clyde J. Wright, MD Assistant Professor Department of Pediatrics

Philadelphia, PA Assistant Professor

Department of Pediatrics, Division of Neonatology

Donald Younkin, MD Professor

Neurology and Pediatrics

Philadelphia, PA Attending Physician Department of Pediatrics Division of Child Neurology Children’s Hospital of Philadelphia Philadelphia, PA

Catherine S. Zorc, MD Fellow, Academic General Pediatrics Department of Pediatrics

Joseph J. Zorc, MD, MSCE Associate Professor of Pediatrics and

Emergency Medicine Perelman School of Medicine University of Pennsylvania Philadelphia, PA Attending Physician Emergency Department

Kathleen Wholey Zsolway, DO Clinical Associate Professor of Pediatrics Department of General Pediatrics University of Pennsylvania Medical School Philadelphia, PA

Medical Director

General Pediatrics Faculty Practice Children’s Hospital of Philadelphia Philadelphia, PA

(21)

(22)

xix

C O N T E N T S

Preface vi Contributors vii

PA R T 1

Introduction

1

Obtaining and Presenting a Patient History 1

Joseph J. Zorc and M. William Schwartz (3rd Edition)

2

The Physical Examination 6

Shoshana Melman

3

Developmental Surveillance 35

Patty Huang

4

Developmental Disabilities 45

Patty Huang

5

Immunizations 55

Alexander G. Fiks

6

^FeedingInfants 66

Susan A. Friedman and Brenda Waber

7

Well-Newborn Care 84

Andria Barnes Ruth and Kathleen Wholey Zsolway

PA R T 2

Problems

8

^Abdominal^{Mass 97}

Marc H. Gorelick

(23)

9

Abdominal Pain, Acute 108

Paul Ishimine

10

Abdominal Pain, Chronic 121

Kristin N. Fiorino

11

Alopecia 139

Catherine S. Zorc

12

Ambiguous Genitalia 145

Jennifer A. Danzig and Lorraine E. Levitt Katz

13

Amenorrhea 155

Valerie Lewis

14

Animal Bites 163

Toni Gross

15

^{Apnea 172}

Thomas Mollen

16

Ascites 178

Evelyn K. Hsu

17

Ataxia 183

Lawrence W. Brown

18

Bleeding and Purpura 193

Kim Smith-Whitley

19

^Chest^{Pain 209}

Kan N. Hor and Bradley S. Marino

20

^Child^{Abuse 217}

Cindy W. Christian

21

^{Coma 228}

Nicholas S. Abend

(24)

CONTENTS xxi

22

Constipation 241

Kristin N. Fiorino

23

^{Cough 251}

Richard M. Kravitz

24

Cyanosis 266

Beth Ann Johnson and Bradley S. Marino

25

Dehydration 274

Philip R. Spandorfer

26

Diabetes 283

Stuart A. Weinzimer

27

^Diarrhea,^{Acute 291}

Catherine C. Wiley

28

^Diarrhea,Chronic 301

Andrew Grossman

29

Drowning 311

Mercedes M. Blackstone

30

Ear, Painful 317

Christine S. Cho

31

^{Edema 326}

René VanDeVoorde

32

Electrolyte Disturbances 335

Christopher J. LaRosa

33

^{Fever 360}

Fran Balamuth and Elizabeth R. Alpern

34

Gastrointestinal Bleeding, Lower 366

Sara Karjoo and Chris A. Liacouras

(25)

35

Gastrointestinal Bleeding, Upper 378

Sara Karjoo and Chris A. Liacouras

36

Goiter 385

Craig A. Alter, Wilma C. Rossi, and Andrew J. Bauer

37

^HeadTrauma 396

Oluwakemi B. Badaki-Makun and Joel A. Fein

38

Headache 404

Nicholas S. Abend and Donald Younkin

39

Hematuria 414

Rebecca Ruebner and Madhura Pradhan

40

Hemolysis 424

Kim Smith-Whitley

41

Hemoptysis 440

Suzanne E. Beck

42

Hepatomegaly 448

Christina Bales

43

Hypertension 462

Kevin E.C. Meyers

44

Hypotonia 466

Lawrence W. Brown

45

Jaundice 475

Evelyn K. Hsu

46

^Jaundice,Newborn 485

Clyde J. Wright and Michael A. Posencheg

47

^Joint^{Pain 504}

Jeffrey A. Seiden

(26)

CONTENTS xxiii

48

Leukocytosis 517

David T. Teachey

49

Leukopenia 527

David T. Teachey

50

Lymphadenopathy 536

Leslie S. Kersun

51

Macrocephaly 546

Lawrence W. Brown

52

Mediastinal Mass 551

Leslie S. Kersun

53

Murmurs 559

Jack Rychik

54

^Neck^{Mass 570}

Monika Goyal and Frances Nadel

55

^NeckPain/Stiffness 577

Jill C. Posner

56

^NeonatalInfections 585

Samir S. Shah

57

^Pallor(Paleness) 601

Kim Smith-Whitley

58

Paraplegia 614

Lawrence W. Brown

59

^Pelvic^{Pain 624}

Sara Pentlicky and Courtney Schreiber

60

^PleuralEffusions 633

Angela Lorts

(27)

61

Precocious Puberty 639

Marta Satin Smith

62

Proteinuria 647

Rebecca Ruebner and Madhura Pradhan

63

Pruritus 654

Paul L. Aronson

64

Rashes 663

Leslie Castelo-Soccio and Kara Shah

65

^Red^{Eye 683}

Cynthia J. Mollen

66

Respiratory Distress 691

Esther M. Sampayo

67

Scrotal Pain, Acute 705

Kate Kraft

68

Seizures 711

Katherine S. Taub and Nicholas S. Abend

69

^Sexual^{Abuse 726}

Cindy W. Christian

70

^SexuallyTransmitted Diseases 734

Lisa K. Tuchman and Amy L. Weiss

71

^ShortStature 750

Dorit Koren and Adda Grimberg

72

^SoreThroat 771

Esther K. Chung

73

Splenomegaly 782

Matthew J. Ryan

(28)

xxv CONTENTS

74

Syncope 793

Jeffrey B. Anderson and Timothy K. Knilans

75

Tachycardia 799

Richard J. Czosek and Timothy K. Knilans

76

Thermal Injuries 809

Andrew Hashikawa and Marc H. Gorelick

77

Urinary Frequency and Polyuria 818

Matthew Sampson

78

Urine Output, Decreased 825

Katherine MacRae Dell

79

^VaginalBleeding 833

80

Vaginal Discharge (Vulvovaginitis) 841

81

^Vertigo(Dizziness) 849

Lawrence W. Brown

82

Vomiting 856

Amanda Muir and Chris A. Liacouras

PA R T 3

Toxicology

83

Toxicology 867

James F. Wiley II and Diane P. Calello

PA R T 4

Cardiology Laboratory

84

Cardiology Laboratory 883

Timothy M. Hoffman

(29)

PA R T 5

Surgical Glossary

85

^SurgicalGlossary 900

PA R T 6

Syndromes Glossary

86

^SyndromesGlossary 906

Index 917

(30)

C H A P T E R

Joseph J. Zorc M. William Schwartz (3rd Edition)

1 Introduction

P A R T 1

1

T

Obtaining and Presenting a Patient History

his chapter presents a guide for obtaining a history of a pediatric patient and presenting a case on rounds or to an audience. Not every item described in this chapter is necessary in every write-up or presentation.

The goal is to communicate key information about a patient; and the reader should not be overwhelmed with details that do not tell the patient’s story.

HISTORY Chief Complaint

Always ask the patient or the parents to describe their concerns, and record their actual words. Starting in an open-ended way may uncover concerns that can be missed if the clinician focuses too early on problem-oriented questions. The age and sex of the patient, as well as the duration of the problem, should be noted when presenting the chief complaint.

HINT: Experienced pediatric clinicians state that most of the key evidence leading to a diagnosis is obtained through the history of the patient. Often, the physical examination and laboratory tests serve to confi rm what the history suggests.

(31)

2

History of Present Illness

Indicate the person who provided the history (e.g., patient, parent, or guardian).

Provide a clear, concise chronology of important events surrounding the problem—when did the problem start, how has it changed over time, and what tests and treatments were performed. Include key negative fi ndings that may contribute to the differential diagnosis.

Medical History

• Prenatal history— mother’s age and number of pregnancies; length of pregnancy; prenatal care, abnormal bleeding, illness, or exposure to illness; and medications or substances used (alcohol, drugs, tobacco) during pregnancy.

• Birth history— birth weight; duration of labor; mode of delivery, use of induc- tion, anesthesia, or forceps; complications; and Apgar scores, if known.

• Neonatal history— length of stay, location (nursery vs. intensive care); complications such as jaundice, respiratory problems; and feeding history.

HINT: Details about birth history are included in a write-up when they are relevant, but generally should be included for all children younger than 2 years.

• Developmental history— milestones for smiling, rolling over, sitting, standing, speaking, and toilet training; growth landmarks for weight gain and length. If delays are present, determine the approximate age at which the child functions for motor, verbal, and social skills.

• Behavioral history— proceed from less to more sensitive areas. The mnemonic SHADSSS can help structure the interview with an adolescent:

School: grades, likes/dislikes, and plans for the future Home: others present and relationship with family Activities: friends and hobbies

Depression: emotions, confi dants, and suicidal thoughts/acts Substance abuse: exposure or use of drugs, tobacco, and alcohol

Sexuality: partners, contraception use, and history of sexually transmitted diseases (STDs)

Safety: violence and access to weapons

• Immunization history —immunizations by type and date, dates of recent boosters, and recent tuberculosis testing results.

HINT: A statement in the patient’s write-up that the patient’s immunizations are “up to date” does not indicate whether recent changes in the recommendations were followed. Specifi c information should be provided when possible.

• Past medical history —childhood illnesses, estimated frequency of infections, and hospitalizations.

• Surgical history —procedures, complications, and dates of each.

(32)

CHAPTER 1 | OBTAINING AND PRESENTING A PATIENT HISTORY 3 Review of Systems

Do not duplicate the history of the present illness in this section of the write-up.

• Head —injuries, headaches, hair loss, and scalp infections.

• Eyes —acuity of vision; use of glasses; history of discharges, abnormal tearing, or injuries; and prior surgery.

• Ears —acuity of hearing and history of otitis, discharges, or foreign bodies.

• Nose —breathing diffi culties, discharges, bleeding, and sinus infections.

• Oral cavity and throat —frequency of sore throats, dental problems, bleeding gums, herpes infections, and ulcers.

• Lungs —exercise tolerance (ability to keep up with peers during exercise), breathing diffi culties, cough (day or night), history of pneumonia, wheezing, pains, hemoptysis, exposure to tuberculosis, and previous chest radiographs.

• Heart —exercise tolerance; history of murmurs; history of rheumatic fever in patient or family; history of Lyme disease or other infections that may affect the heart; feeling of heart racing, dyspnea, orthopnea, palpitations, or chest pain;

cyanosis; and edema.

• Gastrointestinal system —appetite, weight changes, problems with food (e.g., allergy and intolerance), abdominal pain (location, intensity, precipitat- ing events), bowel movements (number and character), jaundice, and rectal bleeding.

• Genitourinary system —history of infection, frequency of urination, dysuria, and hematuria, character of the urine stream, bedwetting, urethral or vaginal discharge, and age of menarche.

• Extremities —joint or muscle pain, muscle strength, swelling, and limitation of movement.

• Neurologic system —seizures, weakness, headaches, tremors, abnormal movements, development, school achievement, and hyperactivity.

• Skin —rashes and type of soap and detergent used.

Family History

• Ages of parents and siblings

• Family history of illness —seizures, asthma, cancer, behavior problems, aller- gies, cardiac disease, unexplained deaths, and lipid disorders

• Deaths in family —causes of death and age of the family member at the time of death

• Social history —other household members, sleeping arrangements, marital status of the parents, parents’ employment status, and health insurance status

HINT: In a patient with a suspected metabolic disorder, the most important question concerns early deaths of the patient’s siblings or cousins. In a patient with a suspected infectious disease problem, the most important question concerns the patient’s contact with others who are ill.

(33)

4

HINTS FOR PATIENT PRESENTATIONS

One of my images of hell is to be forced to spend a day listening to medical students’

case presentations on rounds—both of them.

—Burt Sloane

Consider the Audience and Setting

The group members often have short attention spans, are usually standing, and often have other obligations. Make a brief presentation, no longer than 2 minutes, that provides highlights of the problem and leads the audience to the diagnosis. This is not the time to demonstrate your thoroughness or compulsive nature.

Also consider the style of the preceptor and those attending. Some may prefer a Socratic dialogue; while others want a more detailed presentation. Bear in mind that the Socratic style leads to interactive questions and answers. It is important, however, to appreciate the time pressures of audiences in inpatient rounds or clinics.

In contrast, grand rounds or formal case presentations may last as long as 10 minutes. These presentations focus on a diagnostic dilemma with many differential diagnoses, provide data for someone else to discuss with regard to fi ndings and reaching a diagnosis or treatment, and include detailed histories, many negative fi ndings, and most laboratory test results.

Decide What Information is Important to Include

It is important to decide what negative information to include in the presentation and what to rule out. The negative information should help exclude one or two of the major differential diagnoses. For example, you should mention respiratory distress in a case of cardiac failure but not in a case of urinary tract infection. Likewise, you should mention family history in a case of asthma or mental retardation but not in leg trauma.

After gathering information about the patient’s problem, select the highlights, arranging them in an interesting and logical manner to lead to the diagnosis.

Organize the Presentation The following format is suggested.

Chief Complaint

State in the patient’s or the parent’s words the reason for referral or admission.

Mention the patient’s age and the source of the referral. Avoid starting with a list of descriptors (e.g., “product of a gravida 1, para 1 full-term pregnancy” or “was well until 2 days before admission, when the following events occurred”).

History of Present Illness

Give a summary of the pertinent events preceding admission and the changes in the patient’s condition that precipitated the visit.

Review of the Patient History

Include only information that suggests the diagnosis or rules out major differential diagnoses. Consider the patient’s developmental history, immunization history, past medical history, and family and social history.

(34)

CHAPTER 1 | OBTAINING AND PRESENTING A PATIENT HISTORY 5 Physical Examination Findings

Discuss how the child looked, but include only pertinent positive fi ndings and a few negative fi ndings that help eliminate major differential diagnoses or lead to the diagnosis.

Summary

Summarize the key facts that lead to the suspected diagnosis. Review other diagnoses that are in the differential. Outline your plan to complete the workup. Always think through your diagnosis and plan prior to a presentation, even if you are unsure, because this is the way to strengthen diagnostic skills.

Audience Questions

Be prepared for questions. They are compliments and mean that the audience was listening and thinking about the problem and the information you discussed.

Questions are not criticisms of an incomplete presentation.

(35)

6

C H A P T E R

Shoshana Melman

2 The Physical Examination

GENERAL CONSIDERATIONS Performing the Physical Examination

The physical examination of a child is as much an art as a scientifi c procedure.

The goal is to make the examination as productive and nontraumatic as possible.

To minimize fear in young children, conduct most of the physical examination with the child sitting on the parent’s lap or nestled against his or her shoulder. If the child appears fearful, talk with the parent fi rst so that the child has a chance to study you. Speak quietly, using a friendly tone of voice. Move gently and slowly, avoiding loud, sudden movements.

The physical examination is routinely presented and written in standard (adult) order, although it may not be carried out in that sequence. Children about 8 years and older can usually be examined easily in standard adult order, but with younger patients it is important to examine the most critical areas fi rst, before the child cries. Always start with observation. Next, in a young child with a specifi c presenting complaint, it is often helpful to examine the corresponding organ system. In a young child with no specifi c complaints, palpate the fontanelles and then auscultate the heart and the lungs. Wait until the end of the examination to check the most threatening areas (e.g., the ears and the oral cavity).

Special Concerns Mental Status

Since children often cannot vocalize their symptoms, their overall mental status is an essential clue to their degree of illness. Will the child smile or play? Observe interactions with parents or siblings. Be careful to differentiate a child who is sim- ply tired from one who is lethargic (diffi cult to arouse). Similarly, distinguish the cranky child who comforts easily from one who is truly irritable and inconsolable.

HINT: Cranky, febrile young children are often much more pleasant when their temperature has reduced. Children with meningitis are not easily com- forted by being held; in fact, when picked up they may cry more.

Hydration Status

Physical fi ndings consistent with dehydration include an increased heart rate, decreased blood pressure, sunken fontanelle, dry mucous membranes, decreased skin turgor, and increased capillary refi ll time ( ⬎ 2 seconds).

(36)

CHAPTER 2 | THE PHYSICAL EXAMINATION 7

VITAL SIGNS AND STATISTICS Temperature

Body temperatures are more labile in children than in adults and can be raised depending on the time of day (e.g., in the late afternoon) or following vigorous activity, excitement, or even eating.

A child’s normal oral temperature is similar to an adult’s, typically about 98.6 ° F.

The rectal temperature is typically approximately 1 ° higher than the oral equiva- lent, and an axillary temperature (the least accurate method) is typically about 1 ° lower. Study results regarding the reliability of tympanic thermometers have been mixed; they are often used in low-risk older children.

HINT: An infant or a young child can have a temperature of 103 ° F to 105 ° F, even with a minor infection. In contrast, a sick newborn may have a lower than normal temperature.

Pulse Rate

In an infant, palpate for pulse rate over the brachial artery. In an older child or adult, the wrist is generally the optimal location. Pulse rate is usually 120 to 160 beats per minute in the newborn and steadily declines as the child grows. A typical teenager’s pulse rate would be 70 to 80 beats per minute.

HINT: In infants and children, the pulse rate responds much more distinctly to disease, exercise, or stress than it does in adults.

Respiration Rate

The most accurate measurements are obtained while the patient is asleep. In infants and young children, breathing is mostly diaphragmatic; the respiratory rate can be determined by counting movements of the abdomen. In older children and adolescents, chest movement should be directly observed. Table 2-1 summarizes the normal pediatric respiratory rates.

HINT: Infants typically exhibit “periodic breathing,” short periods of rapid breathing followed by several seconds without a breath. Pauses of 10 seconds or more are abnormal.

TABLE 2-1 Normal Pediatric Respiratory Rates (Respirations/min) Newborns Toddlers School-Aged Children Adolescents

30–50 20–40 15–25 12

(37)

8

Blood Pressure

To obtain an accurate blood pressure measurement, patient relaxation is especially critical. Explain to a young child that the “balloon” will squeeze his arm and encourage him to watch the display.

Cuff width is also important. Choose a cuff width that covers 50% to 75% of the upper arm length. A too-narrow cuff may artifi cially increase the blood pressure reading.

If you are concerned about the possibility of heart disease, check blood pressure in all four extremities. Compare blood pressure measurements with standard norms for age and sex.

Length (Height)

To obtain a length measurement, place the infant on a fi rm table. Hold the baby’s feet against a stationary board, keeping the knees straight, and bring a movable upright fi rmly against the baby’s head to measure the infant’s recumbent length.

Children ⬎ 2 years can be measured with the child standing erect. The child should be positioned with feet fl at, eyes looking straight ahead, and occiput, shoulders, buttocks, and heels against a vertical measuring board.

Figure 2-1 shows the National Center for Health Statistics percentiles for physical growth in girls and boys from birth through the age of 20 years. The Centers for Disease Control and Prevention recommends that health care providers for U.S. children use World Health Organization growth charts to monitor growth for infants and children aged 0 to 2 years and use Centers for Disease Con- trol and Prevention growth charts to monitor growth for children aged 2 years and older.

Weight

Routinely weigh infants unclothed. For patients in whom small variations in weight are important, it is helpful to consistently use a single scale, preferably at the same time of day.

The growth charts in Figure 2-1 include body mass index (BMI) (wt/ht ² ). This number is used in patients ⬎2 years to determine whether weight is appropriate for height. By plotting BMI for age, health care providers can achieve early identi- fi cation of patients at risk for being overweight/obese.

HEAD

Head Circumference

Start your examination of the head by measuring the head circumference at the maximum point of the occipital protuberance posteriorly and at the midforehead anteriorly. Microcephaly (small head size) could result from abnormalities such as craniosynostosis (premature fusion of the cranial sutures) or congenital TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex) infection. Macrocephaly (large head size) could be caused by problems such as hydro- cephalus or an intracranial mass. Figure 2-2 presents normal head circumferences.

(38)

Mother’s Stature Father’s Stature

NAME

RECORD #

Age: Weeks

Gestational L

E N G T H

L E N G T H

W E I G H T

Birth 3 6 9

Birth 3 6 9 12 15 18 21 24 27 30 33 36

2 3 4 5 6 7

10 12 14 16

8 6

lb kg

AGE (MONTHS)

12 15 18 21 24 27 30 33 36 kg

Date Age Birth

Weight Length Head Circ.

Comment AGE (MONTHS)

8 9 10 11 12 13 14 15 16 17 90 95 100 cm cm

100

lb 16 18 20 22 24 26 28 30 32 34 36 38

40 45 50 55 60 65 70 75 80 90 95

85

15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

in in

41 40 39 38 37 36 35 Birth to 36 months: Girls

Length-for-age and Weight-for-age percentiles

Published May 30, 2000 (modified 4/20/01).

SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000).

http://www.cdc.gov/growthcharts

95 90

75

50 25 10 5 9590 75 50 25 105

FIGURE 2-1 National Center for Health Statistics (NCHS). Clinical Growth Charts. A. Girls, birth to 36 months: Length-for-age and weight-for-age. (continued)

(39)

10

2 to 20 years: Girls

Stature-for-age and Weight-for-age percentiles

NAME

RECORD #

W E I G H T

cm

150 155 160 165 170 175 180 185 190

lb 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230

kg 10 15 20 25 30 35 105

45 50 55 60 65 70 75 80 85 90 95 100

20 20

S T A T U R E

40

lb 30 40 50 60 70 80 S T A T U R E

62

42 44 46 48 60 58

52 54 56 in

30 32 34 36 38 40 50

74 76

72 70 68 66 64 62 60 in

kg10 15 20 25 30 35 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

12 13 14 15 16 17 18 19

AGE (YEARS)

160

cm 3 4 5 6 7 8 9 10 11

95

90

75

50 25 10 5 95 90 75 50 25 10 5

Date Age Weight Stature BMI*

Father’s Stature Mother’s Stature

*To Calculate BMI: Weight (kg)⫼Stature (cm)⫼Stature (cm)⫻10,000 or Weight (lb)⫼Stature (in)⫼Stature (in)⫻703

FIGURE 2-1 (Continued) B. Girls, 2–20 years: Stature for age and weight for age percentiles.

(40)

2 to 20 years: Girls

Body mass index-for-age percentiles

NAME

RECORD#

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

28

26

24

22

20

18

16

14

12 30 32 34 BMI

BMI

AGE (YEARS) 13

15 17 19 21 23 25 27

13 15 17 19 21 23 25 27 29 31 33 35

Date Age Weight Stature BMI* Comments

95

90

85

75

50

10 25

5

FIGURE 2-1 (Continued) C. Girls, 2 to 20 years: Body mass index-for-age percentiles. (continued)