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More About This Textbook
Overview
Cambridge Pocket Clinician / Pediatrics is designed to provide a comprehensive review of clinical pediatrics, with advice for appropriate diagnostic and therapeutic interventions for the most common pediatric problems encountered in the clinical setting. The topics are organized under headings on differential diagnosis, evaluation, treatment, complications and prognosis so that the user will find the desired information quickly and easily. Over 200 diseases and conditions are discussed in detail.
Editorial Reviews
From The Critics
Reviewer: Michael Wasserman, MD(Ochsner Clinic Foundation)Description: This book is an encapsulated, clinically oriented summary of approximately 225 disease entities commonly diagnosed in pediatrics.
Purpose: Although not clearly defined, it appears that the book is to serve as a reminder, for "completeness sake," for the clinician in a children's practice setting. The book is concise, with no extra prose, so is an efficient, quick reference. Thus, it provides a help to the practitioner who desires a reference on common clinical diseases.
Audience: "It is appropriately aimed at medical students and residents. "
Features: The book lists the top 225 diseases (or disease states), and provides a two-page bullet point summary about how the clinician should approach the pediatric patient. It is clear and concise, allowing focus for the clinician.
Assessment: "Although the book is well done, it is primarily organized by disease rather than differential diagnosis. Thus, it is most helpful when one already has begun to consider a particular disease, rather than making it easy to cast a wider net of possible etiologies for certain presenting symptoms or laboratory results. "
Product Details
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Read an Excerpt
Cambridge University Press
978-0-521-70936-1 - Pediatrics - Edited by Howard Bauchner, Robert J. Vinci and Melanie Kim
Excerpt
ACETAMINOPHEN POISONING
HENAN SEDIK, M.D., F.A.A.P.
HISTORY AND PHYSICAL
■ History of ingestion:
➢ Tylenol® preparations
➢ Over-the-counter analgesics/cold remedies
■ Toxic dose >150 mg/kg in acute ingestion
➢ Stage I (0.5–24 h):
• Nausea
• Vomiting
• Diaphoresis
• Pallor
• Malaise
➢ Stage Ⅱ (24–72 h): latent period: initial symptoms resolve; hepatic dysfunction develops
➢ Stage Ⅲ (3–7 d):
• Progressive hepatic encephalopathy: jaundice, confusion, hyperammonemia, & bleeding diathesis
TESTS
■ Acetaminophen level: 4 h after ingestion
■ Plotlevel on Rumack and Matthew’s semilogarithmic nomogram
■ Liver function tests
■ Serum toxicology screen for co-ingestions
DIFFERENTIAL DIAGNOSIS
■ Accidental vs. intentional
■ Chronic ingestions
■ Other hepatotoxins
■ Viral hepatitis/hepatic disease
■ Reye’s
MANAGEMENT
■ GI decontamination
■ Antidote: N-acetylcysteine (NAC)
SPECIFIC THERAPY
■ Decontamination:
➢ Gastric lavage: within first hour after ingestion.
➢ Avoid ipecac unless toxic co-ingestion
➢ Activated charcoal:
• All patients w/in 4 h of ingestion
• Consider beyond 4 h for co-ingestions or delayed absorption of acetaminophen (e.g., ingestion of sustained-release preparations or agent that slows gut motility)
■ N-acetylcysteine (NAC):
➢ Antidote
➢ Most efficacious if administered w/in 8 h of ingestion
➢ Use if:
• 4-hour level >150 mcq/mL
• Patient presents 6–8 h after ingestion: give initial dose while level pending
➢ Oral dose: loading dose 140 mg/kg, then 70 mg/kg q4h for 17 doses, diluted 1:4 in a carbonated beverage, PO or NG
➢ Side effects: nausea, vomiting
➢ Repeat dose if patient vomits within 1 h; use antiemetics
➢ Ⅳ NAC (not FDA approved in U.S.) recommended for:
• Pts who cannot tolerate oral NAC due to intractable vomiting & for whom further delay will result in decreased efficacy
• Pts whose medical condition precludes enteral use of NAC (e.g., corrosive ingestion, GI bleeding or obstruction)
• Fulminant hepatic failure
• Pregnancy
FOLLOW-UP
■ Serum acetaminophen level in “minimal risk of hepatic toxicity” range on nomogram (or ingestion <140 mg/kg): sent home
■ Potential hepatotoxicity: admitted for antidote therapy
■ Repeat monitoring of acetaminophen levels at 4 h intervals
■ NAC should not be discontinued if subsequent levels fall below possible hepatic toxic zone
■ Monitor liver function and coagulation profile
COMPLICATIONS AND PROGNOSIS
Complications
■ Fulminant hepatic failure
■ Renal failure
■ Anaphylaxis with Ⅳ NAC
Prognosis
■ No toxicity with ingestion of single dose <150 mg/kg
■ Hepatocellular necrosis: may resolve with ICU care
■ Fulminant hepatic failure: may require transplant
ACNE VULGARIS
PAULINE SHEEHAN, M.D.
HISTORY AND PHYSICAL
■ 85% teenagers & young adults affected
History
■ Risk factors: relative with severe disease, hyperandrogenism
Physical signs
■ Disorder of pilosebaceous unit; prominent on face, chest & back
■ Noninflammatory lesions:
➢ Microcomedones
➢ Open comedones (blackheads)
➢ Closed comedones (whiteheads)
■ Inflammatory lesions:
➢ Papules
➢ Pustules
➢ Cysts
➢ Nodules
TESTS
■ Free & total testosterone & DHEA-S, LH, FSH, prolactin in females who:
➢ Fail traditional therapy
➢ Evidence of hyperandrogenism
DIFFERENTIAL DIAGNOSIS
■ Rash caused by systemic or topical steroids, anticonvulsants, isoniazid
■ Folliculitis
■ Acne rosacea
MANAGEMENT
■ Goal: to prevent scarring and emotional sequelae
■ Noticeable improvement: 6–8 wk
■ Proper usage & dosage of medications important
■ Avoid creams, lotions, cosmetics, hair care products containing oil (use oil-free, non-comedogenic, water-based products)
■ Picking & excessive scrubbing can lead to scarring
SPECIFIC THERAPY
■ Depending on type, severity & distribution of lesions
■ Generally begin w/ topical therapy with keratolytic agent alone or w/ topical antibiotic; then progress to systemic therapy w/ oral antibiotics, OCPs, antiandrogens
■ Non-inflammatory:
➢ Benzoyl peroxide:
• gels, creams, lotions, soaps, shaving creams, washes
• Start w/ water-based gel or cream
• Lower concentrations less irritant
➢ Tretinoin:
• Creams, gels, solutions
• Start with lowest concentrations; work up as tolerated
• Apply thin layer every other night, wash off in am
➢ May add azelaic acid:
• Anti-inflammatory, comedolytic; fades hyperpigmentation
• Less potent than tretinoin but tolerated better
➢ May add adapalene gel: similar effect as tretinoin but less local irritation
➢ Tazarotene gel: for acne & psoriasis
■ Moderate inflammatory:
➢ As for non-inflammatory; then consider:
• Topical clindamycin, tetracycline, or erythromycin
• Add oral therapy PRN: tetracycline, doxycycline, minocycline
• Second-line oral therapy: erythromycin, amoxicillin, cephal-exin
■ Severe inflammatory:
➢ As for moderate inflammatory; then consider:
• Increase frequency & dosage of oral antibiotics
• Consider intralesional steroids, isotretinoin (only for severe recalcitrant acne)
• Oral contraceptives, hormonal therapy (spironolactone)
FOLLOW-UP
■ Re-evaluate in 6–8 wk
■ Adjust therapy accordingly
■ Continue antibiotics for 3 mo & reconsider therapy
■ Judicious use of antibiotics important
COMPLICATIONS AND PROGNOSIS
■ Scarring
■ Hyper- or hypopigmentation
■ Beware psychological impact
ACUTE ABDOMINAL PAIN
JAIME BELKIND-GERSON, M.D.
HISTORY AND PHYSICAL
History
■ Type, character, & radiation of pain
■ Previous abdominal pain
■ Vomiting, diarrhea, bowel function
■ ? GI bleeding
■ Cough, fever
■ Precipitating events, diet
■ Intake of drugs or toxins
■ Trauma
■ Past surgical history
Physical signs
■ Fever
■ Pharyngitis
■ Evidence of pneumonia, costovertebral angle tenderness
■ Location & character of pain
■ Presence or absence of bowel sounds
■ Liver, spleen size
■ Peritoneal signs
■ Rectal exam (test for blood)
■ Pelvic exam/testicular exam
TESTS
■ CBC
■ Urinalysis
■ Abdominal flat plate and upright films
■ Amylase, lipase, ALT/AST, bilirubins, glucose
■ Stool culture and tests for ova and parasites
■ BUN/creatinine
■ Pregnancy test
■ Toxicology screen
■ Chest x-ray
■ Abdominal ultrasound
■ In selected cases, GI contrast studies and/or CT
DIFFERENTIAL DIAGNOSIS
■ Trauma:
➢ Duodenal hematoma
➢ Pancreatitis
➢ Liver or spleen laceration
■ Intra-abdominal medical disorders:
➢ Constipation
➢ Gastroenteritis
➢ Peptic ulcer disease
➢ UTI
➢ Pelvic inflammatory disease (PID)
➢ Pancreatitis
■ Intra-abdominal surgical disorders:
➢ Appendicitis
➢ Intussusception
➢ Complicated pancreatitis
➢ Obstruction from previous surgery
■ Extra-abdominal disorders:
➢ Pneumonia
➢ Psychogenic pain
➢ Testicular or ovarian torsion
➢ Pregnancy
➢ PID
■ Systemic disorders:
➢ Lead poisoning
➢ Sickle cell anemia
➢ Diabetic ketoacidosis
➢ Porphyria
■ Surgical disorder suggested by:
➢ Pain that wakes child at night
➢ Severe pain
➢ Fever, vomiting (particularly bilious or feculent)
➢ Rebound tenderness
➢ Lack of bowel sounds
➢ Abdominal distention
➢ Failure to pass flatus
MANAGEMENT
General measures
■ Avoid analgesics
■ NPO with Ⅳ fluid & electrolyte replacement
■ NG tube for relief of GI obstruction
■ Consider surgical and/or gastroenterologist consult
SPECIFIC THERAPY
■ Varies according to etiology
■ Prompt attention to potential surgical cases is high priority
FOLLOW-UP
■ Frequent contact w/ pt discharged with diagnosis of abdominal pain
COMPLICATIONS AND PROGNOSIS
■ Varies according to etiology:
➢ Dehydration
➢ Electrolyte imbalances
➢ Sepsis
➢ Intestinal perforation, intestinal obstruction, & hemorrhage
Prognosis
■ Very good for most medical disorders (e.g., infectious diarrhea, gastroenteritis, constipation)
■ Excellent for surgical disorders treated in a timely manner (e.g., appendicitis, intussusception, testicular torsion, obstruction due to adhesions, ectopic pregnancy)
ACUTE ASTHMA
SUZANNE F. STEINBACH, M.D.
HISTORY AND PHYSICAL
History
■ Presence/duration: cough, wheeze, shortness/labored/rapid bre-athing
■ Home therapy: # & frequency of steroids, bronchodilator doses
■ Previous attacks:
➢ Use of steroids
➢ ER/hospital/ICU care
➢ Intubation
■ Best baseline peak expiratory flow (PEF)
■ Trigger exposures
Physical signs
■ Respiratory rate
■ Oxygen sat
■ Ability to speak
■ Retractions
■ Trachea midline, crepitus
■ Air entry, inspiratory to expiratory ratio (I:E), wheeze, asymmetries
■ Mental status
TESTS
■ PEF
■ CXR:
➢ Asymmetric exam
➢ Poor response to therapy
■ ABG: poor response to therapy
DIFFERENTIAL DIAGNOSIS
■ Bronchiolitis
■ Laryngotracheobronchitis (croup)
■ Foreign body aspiration
■ Vocal cord dysfunction
■ Airway compression
■ Anaphylaxis
MANAGEMENT
What to do first
■ Assess severity:
➢ Mild:
• Mild tachypnea
• Normal mental status and color
• Speaks in sentences
• ± mild retractions
• PEF >80%
• O2 sat >95%
• PaCO2 <35
• ± end-expiratory wheeze (E)
• Good response
➢ Moderate:
• Moderate tachypnea & retractions
• Normal mental status
• Speaks in phrases
• Pale
• PEF: 50–80%
• O2 sat: 91–95%, PaCO2 <42
• E or inspiratory (I) & E wheeze
• Incomplete response to therapy
➢ Severe:
• Severe tachypnea or apnea
• Depressed or agitated mental status
• ± severe retractions
• Single word or short phrases
• ± cyanotic
• Decreased aeration
• PEF <50
• O2 sat <91, PaCO2 >41
• Poor response to therapy
General measures
■ Reassure
■ Educate
■ Hydrate; avoid overhydration
■ O2: O2 sat >90%
■ Bronchodilators:
➢ Inhaled albuterol
➢ Ipratropium bromide
➢ SQ epinephrine/terbutaline
➢ Ⅳ terbutaline
■ Corticosteroids
SPECIFIC THERAPY
■ Mild:
➢ Albuterol 0.02 mL/kg (max, 1.0 mL) in NS nebulized or 2–4 puffs w/ spacer q20 min up to 3×, then q4 h at home, taper
➢ Consider oral steroids: 1–2 mg/kg (max, 60 mg/d) divided bid for 3–10 d
■ Moderate/severe:
➢ O2 to keep O2 sat >90%
➢ Albuterol 0.03 mL/kg (max, 1.0) in NS nebulized w/ ipratropium q20 min up to 3× or 4–8 puffs with spacer q20 min up to 4 h
➢ Steroids PO or Ⅳ: 2–4 mg/kg/day: in extremis or no response to 1st dose or incomplete response to 2nd dose of albuterol
■ In extremis, can’t do PEF, deteriorates suddenly:
➢ Epinephrine 1:1,000, 0.01 mg = mL/kg sq (max, 0.3–0.5 mL), repeat q15 min × 3
➢ Terbutaline 1:1,000, 0.01 mg = mL/kg sq (max, 0.25 mL)
Side effects and complications of treatment
■ O2: hypoventilation in chronic CO2 retainers
■ Beta-2 agonists: tachycardia, anxiety, tremor, head/abdominal pain, arrhythmias
■ Ipratropium: migratory anisocoria, tremor
■ Steroids: GI upset, acne, hyperglycemia, hypertension, weight gain, hypokalemia, psychosis
Contraindications:
Absolute
■ Sedation, mucolytic drugs
Relative
■ Chest physiotherapy; antibiotics (OK for pneumonia, sinusitis)
FOLLOW-UP
■ Assess after bronchodilator therapy & 1 h later
■ Poor response (persistent severe asthma): transfer to ER or ICU with O2, albuterol, steroids:
➢ SQ epinephrine/terbutaline
➢ Continuous albuterol nebs, 0.5 mg/kg/h
➢ MgSO4 25 mg/kg (max, 2.0 g) q6h
➢ Heliox 70/30
➢ Terbutaline Ⅳ: 10 mcg/kg over 10 min then 0.2 mcg/kg/min, titrate up to max 8 mcg/kg/min; monitor EKG, cardiac enzymes
■ Incomplete response (persistent moderate asthma):
➢ Repeat albuterol q20 min × 3 or space to qh × 3–4 h
➢ Corticosteroids
➢ ER or hospital >3 h
■ Good response (mild asthma):
➢ Space albuterol q2 h
➢ Consider steroids
■ Discharge: <2 signs in moderate category, PEF >80%
■ Follow-up 2–3 days
■ Persistent asthma (see “Chronic Asthma” entry): begin or step up preventive therapy
© Cambridge University Press
Table of Contents
1. Acetaminophen poisoning; 2. Acne vulgaris; 3. Acute abdominal pain; 4. Acute asthma; 5. Acute lymphoblastic leukemia (ALL); 6. Acute otitis media; 7. Acute renal failure (ARF); 8. Acute rheumatic fever (ARF); 9. Adolescent contraception; 10. Adrenal insufficiency; 11. Alopecia (hair loss); 12. Altered mental status; 13. Amenorrhea; 14. Anaphylaxis; 15. Anemia; 16. Animal bites; 17. Ankle injuries; 18. Anorexia; 19. Aortic stenosis (AS); 20. Aplastic anemia; 21. Apparent life-threatening events (ALTE); 22. Appendicitis; 23. Approach to ingestions; 24. Aspirin overdose; 25. Ataxia; 26. Atopic dermatitis; 27. Atrial septal defect (ASD); 28. Attention-deficit hyperactivity disorder (ADHD); 29. Back pain; 30. Bell's palsy/facial palsy; 31. Beta-blocker overdose; 32. Brain tumors; 33. Breast disorders; 34. Breastfeeding basics; 35. Bronchiolitis; 36. Bulimia; 37. Campylobacter infections; 38. Carbon monoxide poisoning; 39. Cardiac arrhythmias; 40. Cat-scratch disease; 41. Cellulitis; 42. Chest pain; 43. Child abuse; 44. Chronic asthma; 45. Chronic renal failure; 46. Coarctation of the aorta; 47. Colic; 48. Congenital adrenal hyperplasia (CAH); 49. Congenital syphilis; 50. Congestive heart failure (CHF); 51. Conjunctivitis; 52. Constipation; 53. Croup (laryngotracheobronchitis); 54. Cyanotic heart disease; 55. Cystic fibrosis; 56. Depression; 57. Developmental dysplasia of the hip; 58. Diabetes insipidus (DI); 59. Diabetes mellitus (DM); 60. Diabetic ketoacidosis (DKA); 61. Diaper dermatitis; 62. Disseminated intravascular coagulation (DIC); 63. Down syndrome; 64. Dysfunctional uterine bleeding; 65. Dysmenorrhea; 66. EBV disease/infectious mononucleosis; 67. Electrical injuries; 68. Endocarditis and prophylaxis; 69. Enuresis; 70. Epididymitis; 71. Epiglottitis; 72. Ethanol poisoning; 73. Evaluation of dysmorphic child; 74. External otitis (swimmer's ear); 75. Failure to thrive; 76. Febrile infants; 77. Febrile seizures; 78. Fever and bacteremia; 79. Foreign body aspiration (FBA); 80. Fragile X; 81. GI foreign body; 82. Gastroesophageal reflux (GERD); 83. General approach to burns; 84. Giardia; 85. Glomerulonephritis; 86. Gonococcal infection; 87. Guillain-barré syndrome; 88. HIV infection in children; 89. Head trauma; 90. Headaches; 91. Hemolytic uremic syndrome; 92. Hemophilia; 93. Hemoptysis; 94. Henoch-schönlein purpura; 95. Hernias and hydroceles; 96. Herpes simplex viral infections; 97. Hirschsprung's disease; 98. Human bites; 99. Hypercoagulable state; 100. Hypertension (HTN); 101. Hyperthyroidism, acquired (graves' disease); 102. Hypogammaglobulinemia syndromes; 103. Hypoglycemia in children; 104. Hypothermia; 105. Hypothyroidism; 106. Hypotonia; 107. Ibuprofen poisoning; 108. Idiopathic thrombocytopenic purpura (ITP); 109. Impetigo; 110. Inborn errors of metabolism; 111. Inflammatory bowel disease (IBD): Crohn's disease and ulcerative colitis (UC); 112. Intussusception; 113. Iron deficiency; 114. Iron poisoning; 115. Jaundice, post-infantile; 116. Juvenile rheumatoid arthritis (JRA); 117. Kawasaki disease (KD); 118. Kidney stones; 119. Knee injury; 120. Language delay; 121. Lead poisoning; 122. Legg-calve-perthes disease; 123. Lice; 124. Lower GI bleeding; 125. Lyme disease; 126. Lymphoma; 127. Malabsorption; 128. Malaria; 129. Malrotation and volvulus; 130. Meningococcal diseases; 131. Mitral valve prolapse (MVP); 132. Molluscum contagiosum; 133. Mumps/parotitis; 134. Murmurs; 135. Mycobacterium tuberculosis; 136. Mycoplasma pneumonia; 137. Myocarditis; 138. Narcotic abstinence syndrome; 139. Near drowning; 140. Nephrotic syndrome; 141. Neuroblastoma; 142. Neurofibromatosis (NF); 143. Neutropenia; 144. Nontuberculous mycobacteria (NTM); 145. Nursemaid's elbow; 146. Obstructive sleep apnea (OSA); 147. Osgood-schlatter disease; 148. Osteomyelitis; 149. Osteosarcoma; 150. Otitis media with effusion (chronic otitis);