Pediatric Primary Care (55 page)

b.  Lymphoma, TB: fever, night sweats, weight loss.

c.  Collagen vascular disease or serum sickness: fever, fatigue, arthralgias.

D.  Physical findings.

1.  General.

a.  Signs of malnutrition, including poor growth: suggestive of chronic disease.

b.  Generalized adenopathy and hepatosplenomegaly: suggestive of malignancy or other noninfectious illnesses and some infectious diseases such as EBV, HIV, TB, histoplasmosis.

2.  Enlargement of the lymph nodes: > 1 cm.

a.  Node-bearing areas: occipital, cervicofacial, axillary, epitrochlear, inguinal, popliteal.

b.  Nodes may be warm, mobile, fixed, fluctuant, solid, smooth.

3.  Presentation, distribution, associated diseases.

a.  Acute posterior cervical lymphadenopathy: rubella, infectious mononucleosis.

b.  Supraclavicular or posterior cervical lymphadenopathy: risk for malignancy.

c.  Cervical lymphadenopathy, associated generalized lymphadenopathy: viral infection.

d.  Generalized lymphadenopathy: associated with leukemia, lymphoma, collagen vascular disease.

e.  Nodes bilateral and soft (not fixed): viral infection.

f.  Tender nodes, possibly fluctuant, not fixed: bacteria.

g.  Redness and warmth: acute pyogenic process.

h.  With fluctuance: abscess formation.

i.  Matted or fluctuant nodes, skin overlying red but not warm: TB.

j.  Nodes hard and fixed, without signs of acute inflammation: associated malignancy.

4.  Associated physical signs.

a.  Markedly red pharynx, possibly exudates, soft palate petechiae: GABHS.

b.  Swelling, redness, tenderness of gums: periodontal disease.

c.  Edema of the soft tissues of the neck: diphtheria.

d.  Sinus tract formation: TB.

e.  Gingivostomatitis: HSV.

f.  Herpangina: coxsackievirus.

g.  Rash: infectious mono, scarlet fever.

h.  Pallor, petechiae, bruises, sternal tenderness.

i.  Hepatosplenomegaly: leukemia.

E.  Diagnostic tests.

1.  Appropriate for suspicion of specific entity.

2.  Throat culture.

3.  PPD.

4.  CBC.

5.  Erythrocyte sedimentation rate (ESR) or (CRP) C-reactive protein

6.  Blood cultures.

7.  Liver enzymes.

8.  Serology for specific microorganisms.

9.  Chest X-ray.

10.  Ultrasound of nodes.

11.  Echocardiogram, ECG.

12.  Fine-needle aspiration for Gram stain and culture.

13.  Biopsy: if malignancy suspected.

F.  Differential diagnosis.

1.  Neck masses.

a.  Congenital lesions are generally painless and most likely identified in infancy.

•  Thyroglossal duct cyst: midline between thyroid bone and suprasternal notch, moves upward.

•  Branchial cleft cyst: smooth, fluctuant, proximal, anterior border of sternocleidomastoid muscle.

•  Sternocleidomastoid tumor: mass in belly of the muscle caused by perinatal injury; associated torticollis.

•  Cervical ribs: bony anomaly.

•  Cystic hygroma: fluid filled, easily transilluminated.

•  Hemangioma.

•  Laryngocele: cystic mass extending through the thyrohyoid membrane.

•  Dermoid cyst: midline cyst, also contains solid components.

•  Parotitis: swelling crosses angle of jaw; mumps.

2.  To summarize: It is reasonable to safely observe nodes that are bilateral, < 3 cm in size, nonerythematous nor exquisitely tender. Treat empirically if: no accompanying systemic symptoms, node > 2-3 cm, unilateral, or erythematous and tender.

G.  Treatment.

1.  Acute cervical lymphadenitis.

a.  Staphylococcus or Group B streptococcus.

•  Patient nontoxic, no abscesses or cellulitis.

i.   Cephalexin–for 10 days; child: 40 mg/kg/day divided bid or qid; adult: 250-500 mg bid or qid.

ii.  Amoxicillin-clavulanate (based on amoxicillin component): 40 mg/kg/day divided bid for 10 days; adult 500-875 mg bid.

iii. Clindamycin: child older than 1 month of age: 8-25 mg/kg/day in divided doses q6-8h; adult: 150-450 mg q6h, max: 1.8 g/day.

•  Patient toxic or immunocompromised.

i.   IV cefazolin, nafcillin, or clindamycin.

b.  Anaerobes: seen with periodontal/dental disease.

•  Penicillin or clindamycin.

c.  Oral analgesia, warm compresses.

d.  Incision and drainage for suppurative, fluctuant nodes.

2.  Consider referral for biopsy if significant lymphadenopathy (> 2 cm in diameter) persists 2 weeks, or no decrease in size after 4-6 weeks or node(s) are supraclavicular, lack inflammation, are firm or rubbery, develop ulceration, fail to respond to antibiotic treatment or there are systemic symptoms (e.g., fever, weight loss, hepatosplenomegaly).

3.  Cervical lymphadenitis abscess: refer for finenveedle aspiration or excision (I&D).

H.  Follow up.

1.  Call if node enlarges, becomes markedly tender, erythematous, indurated.

2.  Call if child appears toxic, has difficulty breathing or swallowing.

3.  If being treated for bacterial infection, call if not better in 48 hours (fever down, tenderness decreased, size of node stable).

4.  Recheck at end of treatment.

5.  Recheck if node(s) persist longer than several weeks.

I.  Complications.

1.  Bacterial: suppuration, bacteremia.

2.  Undiagnosed infectious process or malignancy.

J.  Education.

1.  Address family's fears: primarily those of malignancy.

2.  Compliance with medications.

3.  Observation: when to call, return to clinic.

4.  Hydration.

V.  EPISTAXIS

A.  Etiology.

1.  Bleeding from the nose can be anteriorly from nares (commonly Kiesselbach plexus) or posteriorly into nasopharynx. The nasal mucosa has rich, yet relatively unprotected blood supply. The mucosa is thin, especially in children.

2.  Causative factors.

a.  Inflammation.

•  Infectious processes.

•  Allergies.

b.  Neoplasms, polyps.

c.  Trauma.