Pediatric Primary Care (88 page)

F.  Diagnostic tests.

1.  If child appears ill, dehydrated: serum electrolytes, CBC.

2.  If bilious vomiting, consider upper GI series to rule out mechanical obstruction.

3.  Projectile vomiting in infant younger than 5 months: abdominal ultrasound to rule out pyloric stenosis.

4.  Abdominal flat-plate X-ray: if ingested radiopaque foreign body/bezoar suspected.

5.  Urinalysis with specific gravity.

6.  Other tests to be determined by history, physical exam.

G.  Differential diagnosis.

1.  Infection: usually associated with fever/all ages: viral gastroenteritis, UTI, pneumonia, upper respiratory tract infections (otitis media, sinusitis, pharyngitis).

2.  Mechanical: pyloric stenosis, infants, malrotation/volvulus (infants, children: bilious vomiting, abdominal pain, anorexia), foreign body ingestion or bezoar (children), Hirschsprung's disease (infants: delayed passage of meconium, constipation).

3.  Metabolic: inborn errors of metabolism (infants, rare).

4.  CNS: migraine (children, adolescents: headache, photophobia, family history common), brain tumor (rare), labyrinthitis.

5.  Medication overdose, reaction, toxic ingestion (including lead).

6.  Overfeeding (infants): normal physical exam, review feeding techniques.

7.  Pregnancy: consider in postmenarchal girls.

8.  Bulimia.

9.  Inflammatory bowel disease (child, adolescent): Crohn's disease, ulcerative colitis. Hematochezia, melena, abdominal pain, diarrhea, weight loss, anemia.

H.  Treatment.

1.  Treat, prevent dehydration.

a.  Mild-moderate dehydration: oral rehydrate solution 5 mL every 1-5 minutes plus replacement of estimated volume of emesis. Mild dehydration: goal 50 mL/kg + losses over 4 hours. Moderate: 100 mL/ kg + losses over 4 hours, reassess hourly.

b.  Severe dehydration: emergency department or admission for IV fluids. Start with normal saline or lactated Ringer's solution at 10-20 mL/kg over 1 hour.

2.  As vomiting decreases, offer larger amounts of ORS at less frequent intervals.

3.  After rehydration, other fluids including milk, food may be reintroduced.

4.  Antiemetic medications are generally not warranted/recommended.

I.  Follow up.

1.  No/mild dehydration: Telephone next day.

2.  Moderate dehydration: See patient next day.

3.  Immediate return if increased symptoms, signs of dehydration.

4.  Severe dehydration requires visit following discharge from emergency department/hospital.

J.  Complications.

1.  Dehydration.

2.  Mallory-Weiss tear (linear tear at gastroesophageal junction from repeated vomiting): fresh red blood in emesis after multiple episodes of vomiting.

3.  Other complications depend on etiology.

K.  Education.

1.  Most cases of acute vomiting are from viral gastroenteritis.

2.  Can be successfully treated at home if no signs of or mild dehydration.

3.  Review dehydration signs/symptoms with family, reassure most cases self-limited.

4.  Repeated vomiting can induce reflux of bile into stomach resulting in bile staining.

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CHAPTER 27

Genitourinary Disorders

Shelly J. King

I.  MALE GENITALIA DISORDERS

A.  Cryptorchidism.

B.  Etiology/incidence.

1.  Cryptorchid testes can be absent, undescended, ectopic.

2.  Can be result of chromosomal, hormonal, anatomic factors.

3.  Majority (about 80%): palpable, are undescended or ectopic testes. Retractile testes: also palpable, sometimes misdiagnosed as undescended. Nonpalpable (20%) can be intra-abdominal, inguinal, absent testes.

C.  Occurrence.

1.  Most common male congenital anomaly, affects nearly 1% of term infants.

D.  Clinical manifestations.

1.  Risk of cryptorchidism increases in premature infant.

2.  Bilateral nonpalpable testes or cryptorchid testes associated with hypospadias should be evaluated at birth for life-threatening intersex conditions such as congenital adrenal hyperplasia.

3.  Parents may note retractile testicles in scrotum intermittently, especially after warm bath. Retractile testes are associated with an overactive cremasteric reflex. When examined they can be placed in the scrotum and will remain there for a short time after released. If they retract immediately they should be considered undescended.

4.  In case of absent testicle, contralateral testicle may be larger than expected.

E.  Physical findings.

1.  Often helpful to have child in cross-legged sitting position for exam.

2.  Retractile testes can be placed into scrotum, remain there for short period.

3.  Nonpalpable testes maybe ectopic, found in femoral or perineal regions.

4.  Scrotum may be flat/underdeveloped on affected side.

5.  Larger than expected testicle may represent absent or nonfunctioning testicle on contralateral side.

F.  Diagnostic tests.

1.  Unilateral or bilateral palpable testes: No diagnostic testing indicated.

2.  Bilateral nonpalpable testes or unilateral nonpalpable testes associated with phallic abnormality: Evaluate with karyotype, endocrine testing, appropriate radiographic studies.