Part VIII The Acutely Ill Child
■ Chapter 60 ■ Evaluation of the Sick Child in the Ofﬁce and Clinic Paul L. McCarthy
There are many reasons for a sick child visit, but most are due to acute self-limited intercurrent infections; often the child is febrile. When evaluating an acutely ill, febrile child, the pediatrician must be aware of categorical statistics about the probable occurrence ofserious illness, because one of the major goals of the sick child visit is to identify the seriously ill child who requires speciﬁc therapeutic intervention. The risk for and the cause of serious illness in the acutely febrile child vary, depending on age. The infant in the 1st 3 mo of life is more susceptible to sepsis and meningitis caused by group B streptococci and gram-negative organisms. Infantsin the 1st mo of life are at highest risk. Urinary tract infections are more frequent in males; infants in this age group more often have an underlying anatomic abnormality of the urinary tract than do older children with urinary tract infections (see Chapter 538). As the infant matures beyond 3 mo, the bacterial pathogens that usually cause bacteremia, sepsis, and meningitis are Streptococcuspneumoniae, Haemophilus inﬂuenzae type b (if the child is unimmunized or only partially immunized), and Neisseria meningitidis. Immunization against some serotypes of S. pneumoniae may reduce the occurrence of occult bacteremia and serious infections caused by that organism, as has immunization against H. inﬂuenzae type b. After infancy, urinary tract infections are seen more often in females.Immunity develops rapidly to the common bacterial pathogens during the ﬁrst 3–4 yr of life. N. meningitidis is the leading cause of bacterial meningitis. In children older than 36 mo, pharyngitis caused by group A streptococci is a common bacterial infection. Mycoplasma pneumoniae assumes increasing importance as a cause of pulmonary inﬁltrates in children older than 5 yr of age. Table 60-1 showsserious illnesses documented in children in the 1st 3 yr of life who presented with fever and acute illness at a university hospital and private practice. In many studies, urinary tract infections are the most common serious bacterial infections. Soft tissue infections due to streptococcus or staphylococcus may include cellulitis, fasciitis, osteomyelitis, and septic arthritis. Noninfectious, butserious disease should also be considered and include trauma (abuse), midgut volvulus, appendicitis, intussusception, poisoning (salicylates), metabolic disorders (hypoglycemia, hyperammonemia), neurologic disorders (seizures, infant botulism), or inﬂammatory diseases (Kawasaki disease, juvenile rheumatoid arthritis, Henoch-Schönlein purpura). The acutely ill child with a serious illness is identiﬁedby careful observation, history taking, physical examination, appreciation of age and body temperature as risk factors, and the judicious use of screening laboratory tests. The physician can use the data to make informed decisions about the need for more deﬁnitive laboratory tests (urine culture), therapy, and the advisability of hospital admission. Observation, history, and physical examinationare integrated when the sick child evaluation is being done; that is, as the child is being observed, historical data are gathered. History taking and observational assessment often continue as the physical examination is performed. If abdominal tenderness is found on examination, additional history about blood in the stool, cramping abdominal pain, and vomiting may be sought.
OBSERVATIONObservation is important in the evaluation of the acutely ill child. The child should be observed for speciﬁc evidence of a serious illness, such as grunting, which might indicate pneumonia or sepsis, or a bulging fontanel, which might indicate bacterial meningitis or head trauma. Most observational data that the pediatrician gathers during an acute illness should focus, however, on assessing the...
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