Assessing the Student: When to Refer

Alison Asaro, MD, FAAP

Regional Pediatrician

Mid-Cumberland Region

History Taking: The Seven Attributes of a Symptom

• Location – where is it? • Quality – what is it like? how did it start? • Quantity or severity – how bad is it? • Timing – when did it start? is it constant or intermittent? • Setting – does it occur indoors/outdoors,

before/during/after meals, during day or at bedtime, etc?

• Relieving or exacerbating factors – what makes it better/worse?

• Associated symptoms – does anything else accompany it?

Fever Facts and Definition

• Fever is a sign of illness rather than a disease • Fever is a weapon that the body uses to fight infection • The presence or absence of fever does not indicate how

serious or contagious a particular illness is • A study on fever revealed only 8% of the studied

population (n=148) had a baseline temperature of 98.6 • Fever is defined as follows: Rectal -- greater than 100.4°F Oral -- greater than 100.4°F Axillary -- greater than 99.5°F Tympanic -- greater than 100.4°F

Management: Fever

• Assess the primary complaint!

• The decision of whether or not to send the child home is 100% dependent on his associated symptoms

• If no other acute complaints and/or mild constitutional symptoms, reassess after acetaminophen or ibuprofen administered

• Notify parent and consider sending child back to class depending on symptoms

History: Ear Discomfort

• Ear pain, may be severe • Ear pain worsens with chewing/motion • Otorrhea • Foreign body • Hearing loss, or ear “stuffiness” • Itchy ear • Recent swimming or trauma • Other symptoms: vertigo, tinnitus, fever,

nausea, vomiting, decreased appetite

Exam: Ear Discomfort

• Fever

• Periauricular area: tenderness, redness, swelling, lymphadenopathy, trauma

• External ear

– Redness, swelling, tenderness (especially to traction), trauma, scaling or crusting of skin

Exam: Ear Discomfort (cont.)

• External auditory canal

– Purulent or serous secretions, narrowing, redness, swelling, dried blood or scabs, foreign body

• Tympanic membrane

– Red, dull, retracted, bulging, perforated

• Middle ear

– May visualize serous or purulent middle ear fluid, or a white mass behind the tympanic membrane

Ear Discomfort due to Otitis Media

• Exam: Normal external ear and auditory canal; tympanic membrane red, dull, perforated, and/or bulging; purulent middle ear fluid

• Management – Acetaminophen or ibuprofen for pain and/or fever

– If pain well-controlled and patient otherwise well, may remain in school and follow-up with PCP in 24 hours

– If pain not well-controlled, patient appears sick/toxic, or has otorrhea, send to PCP on same day

Normal tympanic membrane vs. Acute otitis media

http://www.pedisurg.com/PtEducENT/Otitis_Media.htm

Ear Discomfort due to Otitis Externa

• Exam: external ear may be red, swollen, tender to touch and/or traction; redness and swelling of the canal which may cause narrowing or occlusion; serous to purulent secretions in canal; tympanic membrane may appear dull or red

• Management – Acetaminophen or ibuprofen for pain – If pain well-controlled and patient non-toxic, may

remain in school with referral to PCP in next 24 hours – If pain poorly controlled and/or patient toxic, refer to

PCP on same day

Ear Discomfort due to Otitis Media with Effusion

• Exam: Tympanic membrane retracted, red, and/or dull; air bubbles seen in middle ear

• Management – Acetaminophen or ibuprofen for pain

– Unless pain poorly controlled, child may remain in school with guidance to follow-up with PCP as soon as possible, especially if any associated hearing loss

Otitis Media with Effusion

Cholesteatoma

History: Cough

• Acute or chronic onset • Nasal congestion • Production of mucus • Sore throat, dysphagia • Allergy symptoms • Fever • Recent choking episode • Relation to a meal • Dyspnea, chest tightness and/or pain • Medication

– ACE inhibitors

• Known chronic or recent disease – Ex. gastroesophageal reflux, asthma, pneumonia, heart disease

Exam: Cough

• Respiratory effort – Tachpnea, retractions, grunting, nasal flaring, difficulty speaking

• Cyanosis – Look at subungual and perioral areas, may be subtle

• Oropharyngeal exam will often be normal – Look for asymmetry in a child who also has sore throat and/or

difficulty swallowing

• Lung exam may demonstrate clear fields, wheeze, crackles, or diminished/asymmetrical breath sounds – If localized wheeze, consider foreign body aspiration

Management: Cough

• If known disease causing cough, refer to PCP • Send the child home if cough interferes with his

or other student’s classroom time • Immediate referral to ED

– Respiratory distress, cyanosis/hypoxia, recent choking with tachypnea and/or wheezing, hemoptysis, unable to swallow

• Referral to PCP – Fever, allergy symptoms, productive cough without

respiratory distress, nasal congestion, malaise, post-tussive emesis, choking episode days or weeks ago

History: Sore Throat

• Painful swallowing, or inability to swallow with drooling

• Cough

• Nasal congestion or rhinorrhea

• Fever

• Headache

• Nausea, vomiting

• Rash

• History of sexual activity

• Malaise, decreased appetite

Exam: Sore Throat

• Pharynx may appear normal to severely red

• Tonsils may appear normal to severely red, swollen, and/or coated with exudate

• Asymmetrical swelling with uvula displaced

• Petechiae on posterior palate

• Tender lymphadenopathy

• Fever

• Dehydration

Diagnosis and Management of Viral Pharyngitis

• Diagnosis depends on associated symptoms • Sore throat usually accompanied by cough,

nasal congestion, and/or rhinorrhea • Management

– No rapid antigen test needed – Address hydration and analgesia issues, may remain

in school that day if comfortable and well-hydrated – If poor hydration and/or uncomfortable, may send

home with PCP follow-up in next 24 hours as long as child can take fluids and maintain good urine output

– If child is dehydrated and/or toxic, refer to ED

Diagnosis of Bacterial Pharyngitis

• Painful swallowing in the absence of cough and nasal symptoms

• Acute onset often with prodrome of nausea, headache, malaise

• Acute “sandpaper” rash

• High fever

• Tender submandibular lymphadenopathy

• May see asymmetrical swelling of the pharynx with or without deviation of the uvula

Streptococcal Pharyngitis

Management of Bacterial Pharyngitis

• Rapid strep antigen test positive

• Emergent concerns: Toxic appearance, inability to swallow, drooling, dehydration, asymmetrical swelling of pharynx with deviation of uvula

• Send to PCP for antibiotic management

• Send to PCP promptly if concerns regarding analgesia and/or hydration

• Send to ED if toxic appearance or if hydration issues cannot be addressed by PCP

History: Ankle Injury

• Acute or delayed presentation, detail the mechanism of injury and functional limits

• Fracture

– Usually occur after ankle eversion

• Sprain

– Usually occur after ankle inversion

– Often a “pop” is reported

Physical exam: Ankle injury

• Deformity of joint depends on the extent of injury

• Pain, swelling, bruising

• Gently check range of motion

• Palpation for tenderness – Use very gentle pressure initially to minimize

discomfort, may then increase pressure

– Suspect fracture if obvious point tenderness

Management: Ankle Injury

• Rest/keep joint immobilized

• Ice

• Elevation of ankle

• May give ibuprofen, acetaminophen, or naproxen for pain

• Refer to PCP

• May decide to refer to ED if exam suspicious for acute fracture

Migraine Headache

• More than 75% of children complain of headache at least once by 15 years old

• Most chronic headaches in children are migraines

• Most important task is excluding “ominous headache”

• Any headache related to head injury/trauma should be referred to the PCP or ED that day

http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=197414&ts=100507123411

Prototype for “Ominous Headache”: Brain Tumors

History: Migraine Headache

• Onset

• Provocative and Palliative factors

• Quality

• Radiation to other regions

• Severity

• Temporal pattern

• Typical history -- paroxysmal headache with nausea, vomiting, abdominal pain that is relieved by sleep

Exam: Migraine Headache

• Blood pressure

• Visual acuity exam

• Signs of seasonal/year-round allergies

• Neurological exam should be completely normal and there should be no external signs of head trauma

Management: Migraine Headache

• Analgesics – Acetaminophen, ibuprofen

• Rest

• If headache resolves and/or student feels well enough, may contact parent and have child return to class

• Refer for optometry exam if non-acute decrease in visual acuity

Management: Migraine Headache (cont.)

• Refer to PCP if recurrent headaches to discuss non-pharmacologic management, even if headache resolves

• Reasons to refer to PCP or ED that day

– Blood pressure over 95% for age/gender/height

– Focal neurologic findings, or “ominous headache”

– Recent head trauma, esp sports-related

– Headache does not resolve with rest and analgesics, or is getting progressively worse

History: Bacterial sinusitis

• SYMPTOMS PERSIST FOR AT LEAST 10 DAYS AND ARE NOT IMPROVING

• Mucopurulent secretions in the nasal passage – Discharge lasts at least 10 days

• Facial pressure/pain • Headache • Intermittent fever • Cough, worse at night • Halitosis • Recent relapse of nearly resolved URI • Rarely toothache may accompany symptoms

Exam: Sinusitis

• Mucopurulent drainage in the nasal passages, and possibly visualized in the posterior oropharynx

• Sick or “run down” appearance

• Cough

• Normal lung exam

• Fever

• Tenderness to palpation over maxillary and/or ethmoid sinuses

Management: Sinusitis

• Symptomatic care – Systemic decongestants may be used

• Analgesics/antipyretics – Acetaminophen, ibuprofen as needed

• Refer to PCP that day if moderate to severe symptoms – Antibiotics may be recommended, but are not always necessary

• Refer to PCP if no resolution of mild symptoms in two weeks – Mild symptoms are usually viral and will resolve approximately

two weeks

History: Syncope

• Transient loss of consciousness • Incident information

– Occurred during what activity? Details of incident?

• Recent head injury • Psychological disorders

– Emotional upset, hysteria, panic disorders

• Recent history – Illnesses, dehydration, meal skipping, eating disorders – Associated symptoms: chest pain, palpitations, shaking,

hyperventilation or breath-holding – Pregnancy, low blood pressure, seizures, arrhythmia, structural

heart disease, medications, illicit drug use, chronic medical conditions

Exam: Syncope

• Assess level of consciousness – If patient does not immediately regain consciousness,

has obvious external signs of head injury, or is acutely confused, call 911

– Responds appropriately to questions but appears fatigued

– Normal mental status

• Blood pressure • Blood glucose • Cardiac/circulatory exam • Lung exam

Management: Syncope

• Encourage patient to lie down in supine position

• If normal mental status and medically stable…

– Dehydration: offer fluids

– Blood glucose < 70: offer juice or snack

– Low blood pressure: offer fluids

• Refer to PCP that day if possible

• Refer to ER and/or call 911 if not medically stable

History: Urinary Tract Infection

• Urinary frequency, urgency • Painful urination • Urge incontinence • Suprapubic pain • Gross blood in urine, tea-colored urine • Back and/or abdominal pain • Fever • Nausea/vomiting • Constitutional symptoms • Recent sexual activity • Past medical history

Exam: Urinary Tract Infection

• General appearance may be well or toxic

• Urine dip positive for hematuria, leukocyte esterase, nitrites, +/- proteinuria

– Urine may be grossly cloudy or bloody

• Fever

• Abdominal, flank, and/or suprapubic tenderness

Management: Urinary Tract Infection

• Refer to PCP that day if possible for further management, esp if signs of pyelonephritis

– Back pain, fever, toxic appearance

• If suspected urinary tract infection not confirmed, consider possibility of external irritation/trauma or sexually transmitted disease

History: Abdominal Pain

• Acute versus chronic

• Recent abdominal trauma

• Associated symptoms: constipation, diarrhea, emesis, fever, blood in stools, dysuria, etc.

• Exacerbating and relieving factors

• Relation to psychological or mental stress

• Assess for possibility of pregnancy

Exam: Abdominal Pain

• General appearance of child

• Listen for bowel sounds in all four quadrants

• Prior to palpating the abdomen, it is important to try to relax and/or distract the child

• Palpation – Only 1-2 cm of liver edge should be palpable at right

upper quadrant

– Attempt to detect any masses

– Assess for rebound and/or guarding

History/Exam: Alarm Signs and Symptoms

• Involuntary weight loss

• Deceleration of linear growth

• GI blood loss

• Significant emesis

• Abnormal or unexplained physical findings (ex. rash, scleral icterus, or jaundice)

• Pain that wakes child

• Chronic severe diarrhea, especially if nocturnal

• Persistent RUQ/RLQ pain

• Unexplained fever

• Family history of inflammatory bowel disease

• Dysphagia

History/Exam: Alarm Signs and Symptoms (cont.)

• Significant emesis

– Bilious vomiting

– Protracted vomiting

– Cyclical vomiting

– Any worrisome pattern (very subjective)

• Abnormal exam – Localized tenderness

in the RUQ or RLQ

– Localized fullness or mass effect

– Tenderness over the spine

– Costovertebral angle tenderness

– Perianal abnormalities

– Arthritis

Management: Abdominal Pain

• For pain with accompanying alarm signs and/or symptoms, refer to PCP that day or ED immediately – Depends on subjective assessment of acuity

• If reflux or heartburn-type pain, consider offering antacid and encouraging upright recovery position in office

• If acute pain with no alarm signs and symptoms resolve, consider notifying parent and sending child back to class

• If acute pain with no alarm signs and symptoms continue and threaten to interrupt child’s classroom experience, refer to PCP

Management: Abdominal Pain (cont.)

• For chronic abdominal pain with no alarm signs and/or symptoms, encourage child to return to class after short rest period

• Strongly consider developing a management plan for chronic abdominal pain with family and child’s PCP

Common Rashes

• It is very important to be able to distinguish between contagious and non-contagious rashes

• Children with rashes consistent with contagious illness can either be covered to allow a child to complete the school day or referred immediately to the PCP – Dependent on the surface area and location of the

rash

• Referral to PCP may also be dependent on associated symptoms and student’s willingness to comply with plan

Atopic Dermatitis/Eczema

Psoriasis

Abscesses and cellulitis

Acanthosis nigricans

Scabies

Tinea capitis

Tinea corporis

Pityriasis versicolor (formerly tinea versicolor)

Fifth Disease/Erythema Infectiosum

Herpes Simplex

Molluscum

Contagiosum

Impetigo

A note on asymptomatic high blood pressure…

• Normal blood pressure (BP) in children is defined by BP below the 90th percentile for age, gender, and height

– http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html

• Consider causes of asymptomatic high blood pressure

– Overweight/obesity, renal disease, pain/discomfort, anxiety, drug use (illicit or rx), heart disease, etc.

• Refer children with asymptomatic blood pressure at or above the 90th percentile to their PCP

– If child is anxious or in pain, try to ease the child’s primary issue and then reassess BP manually

Questions?