No child will be present; the mother will relate the story. When you enter the examination room, you may see a telephone with instructions to pick up the handset. Upon doing so, you will be speaking to the parent of the child.
Key History
Severity, duration; associated localizing symptoms such as rash, wheezing, cough, and ear discharge; poor appetite, convulsions, lethargy, sleepiness; sick contacts, day care, immunizations.
Key Physical Exam
Vital signs; HEENT, neck, heart, lung, abdominal, and skin exams.
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Presentation |
Differential |
Workup |
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■ 20-day-old M presents with fever, decreased breastfeeding, and lethargy. He was born at 36 weeks as a result of premature rupture of membranes. |
Neonatal sepsis Meningitis Pneumonia Pyelonephritis |
Physical exam CBC Electrolytes Blood culture LP—CSF analysis CXR UA, urine culture |
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■ 3 yo M presents with a 2-day history of fever and pulling on his right ear. He is otherwise healthy, and his immunizations are up to date. His older sister recently had a cold. The child attends a day care center. |
Acute otitis media URI Meningitis Pyelonephritis |
Physical exam (including pneumatic otoscopy) CBC Blood culture Tympanocentesis culture LP—CSF analysis UA, urine culture |
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CHILD WITH FEVER (cant'd) |
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Presentation |
Differential |
Workup |
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■ 12-month-old M presents with fever for the past 2 days accompanied by a maculopapular rash on his face and body. He has not yet received the MMR vaccine. |
Measles (or other viral exanthem) Rubella Roseola Fifth disease Varicella Scarlet fever Meningitis |
Physical exam CBC Viral antibodies/titers Throat swab for culture LP—CSF analysis |
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■ 4 yo M presents with diarrhea, vomiting, lethargy, weakness, and fever. The child attends a day care center where several children have had similar symptoms. |
Gastroenteritis (viral, bacterial, parasitic) Food poisoning UTI URI Volvulus Intussusception |
Physical exam Stool exam and culture CBC Electrolytes UA, urine culture AXR |
No child will be present; only the parent will relate the story, either in person or by telephone.
Key History
Onset, location, quality, intensity, duration, radiation, timing (relation to meals); associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic); changes in weight, skin rash, bloody/mucoid stools, change in stool color; exacerbating and alleviating factors; history of similar symptoms; history of abdominal surgeries; medications; sick contacts, day care, immunizations.
Key Physical Exam
Vital signs; exam for signs of dehydration (BP, heart rate, skin turgor); heart and lung exams; abdominal exam; rectal exam; pelvic exam (women).
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CHILD WITH GI SYMPTOMS (cont'd) |
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Presentation |
Differential |
Workup |
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■ 1-month-old F is brought in because she has been spitting up her milk for the last 10 days. The vomiting episodes have increased in frequency and forcefulness. Emesis is nonbloody and nonbilious. The episodes usually occur immediately after breastfeeding. She has stopped gaining weight. |
Pyloric stenosis Partial duodenal atresia GERD Gastroenteritis Hepatitis UTI Otitis media |
Physical exam CBC Electrolytes U/S—abdomen Barium swallow pH probe Endoscopy AST/ALT/bilirubin/ alkaline phosphatase UA, urine culture Tympanocentesis culture |
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■ 3 yo M presents with constipation. The child has had 1 bowel movement per week since birth despite the use of stool softeners. At birth, he did not pass meconium for 48 hours. He has poor weight gain. There is a family history of this problem. |
Hirschsprung’s disease Low-fiber diet Anal stenosis Hypothyroidism Lead poisoning |
Physical exam Rectal exam Stool exam and culture Barium enema Suction rectal biopsy Anorectal manometry TSH, FT4 CBC Electrolytes Serum lead level |
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■ 8-month-old F presents with sudden-onset colicky abdominal pain with vomiting. The episodes are 20 minutes apart, and the child is completely well between episodes. She had loose stools several hours before the pain, but her stools are now bloody. |
Intussusception Appendicitis Meckel’s diverticulum Volvulus Gastroenteritis Enterocolitis Blunt abdominal trauma |
Physical exam Rectal exam, stool for occult blood CBC Electrolytes Contrast enema U/S—abdomen CT—abdomen |
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■ 7 yo M presents with abdominal pain that is generalized, crampy, worse in the morning, and seemingly less prominent during weekends and holidays. He has missed many school days because of the pain. Growth and development are normal. His parents recently divorced. |
Somatoform disorder Malingering Irritable bowel syndrome Lactose intolerance Child abuse |
Physical exam CBC Electrolytes U/S—abdomen CT—abdomen Amylase, lipase Stool exam |
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CHILD WITH GI SYMPTOMS (cant'd) |
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Presentation |
Differential |
Workup |
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■ 2-month-old M presents with persistent crying for 2 weeks. The episodes subside after passing flatus or eructation. There is no change in appetite, weight, or growth. There is no vomiting, constipation, or fever. |
Colic Formula allergy GERD Lactose intolerance Strangulated hernia Testicular torsion Gastroenteritis |
Physical exam Rectal exam, stool for occult blood U/S—abdomen U/S—testicular |