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  1. Oliver Dorigo, M.D., Ph.D.
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Perspectives on Sexual and Reproductive Health. Prenatal Diagnosis. Seminars in Perinatology. BMC Pregnancy and Childbirth. LGBT Health. Reproductive BioMedicine Online. Maternal and Child Nutrition. Reproductive Health. Infectious Diseases in Obstetrics and Gynecology. Journal of Sexual Medicine.

International Breastfeeding Journal. Molecular Human Reproduction. Acta Obstetricia et Gynecologica Scandinavica. Fetal Diagnosis and Therapy. Journal of Assisted Reproduction and Genetics. Clinics in Perinatology. Sexual Medicine Reviews. Maternal and Child Health Journal. Reproductive Biology and Endocrinology. Journal of Perinatology. Archives of Women's Mental Health. Vital Signs: Temperature fever , pulse tachycardia , respiratory rate tachypnea , BP hypotension. Skin: Capillary refill, rashes, petechia, purpura meningococcemia. Head: Bulging or sunken fontanelle. Eyes: Extraocular movements, papilledema, pupil reactivity, icterus.

Neck: Nuchal rigidity. Brudzinski's sign neck flexion causes hip flexion ; Kernig's sign flexing hip and extending knee elicits resistance. Chest: Rhonchi, crackles, wheeze. Heart: Rate of rhythm, murmurs. Extremities: Splinter hemorrhages endocarditis. Neurologic: Altered mental status, weakness, sensory deficits.

Electrolytes, BUN, creatinine. CBC with differential, blood cultures, smears and cultures from purpuric lesions: cultures of stool, urine, joint fluid, abscess; Urinary Tract Infection 33 purified protein derivative PPD. History of Present Illness: Dysuria, frequency voiding repeatedly of small amounts , malodorous urine, incontinence; suprapubic pain, low-back pain, fever, chills pyelonephritis , vomiting, irritability; constipation.

Urine culture results suprapubic aspiration or urethral catheterization. Past Medical History: Urinary infections. Note whether the patient looks toxic or well. Heart: Rhythm, murmurs. Abdomen: Suprapubic tenderness, costovertebral angle tenderness pyelonephritis , renal mass, nephromegaly. Lower abdominal mass distended bladder , stool in colon. CBC with differential, electrolytes. Ultrasound, voiding cystourethrogram, renal nuclear scan. History of Present Illness: Duration of generalized or regional adenopathy. Fever, pattern, spiking fevers, relapsing fever, rash, arthralgias.

Sore throat, nasal discharge, cough, travel history. Animal exposure cat scratch, kittens. Localized trauma or skin infection, exposure to tuberculosis, blood product exposure. Conjunctivitis, recurrent infections. Past Medical History: Developmental delay, growth failure. Social History: Intravenous drug use, high-risk sexual behavior. Lymphadenopathy and Lymphadenitis 35 Medications: Phenytoin. Review of Systems: Weight loss, night sweats, bone pain. Pallor, easy bruising. Vital Signs: Temperature fever , pulse tachycardia , blood pressure, wide pulse pressure hyperthyroidism.

Lymph Nodes: Generalized or regional adenopathy. Location, size of enlarged lymph nodes; discreteness, mobility, consistency, tenderness, fluctuation. Supraclavicular or posterior triangle lymphadenopathy. Skin: Lesion in the area s drained by affected lymph nodes. Sandpaper rash scarlet fever , punctums, pustules, splinter hemorrhages endocarditis , exanthems or enanthems, malar rash systemic lupus erythematosus.

Eyes: Conjunctivitis, uveitis.

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Chest: Breath sounds, wheeze, crackles. Abdomen: Tenderness, masses, hepatomegaly splenomegaly. Extremities: Joint swelling, joint tenderness, extremity lesions, nasopharyngeal masses. Needle aspiration of the node, after saline infusion, for Gram's stain and acid-fast stains, and culture for aerobes, anaerobes, and mycobacteria. Cat scratch bacillus Bartonella henselae titer. History of Present Illness: Warm, red, painful, indurated lesion. Fever, chills, headache; diarrhea, localized pain, night sweats. Insect bite or sting; joint pain. Review of Systems: Animal exposure pets , travel history, drug therapy.

Family History: Diabetes, cancer. Skin: Warm, erythematous, tender, indurated lesion. Poorly demarcated erythema with flat borders. Bullae, skin breaks, petechia, ecthyma gangrenosum purpuric of Pseudomonas , pustules, abscesses. Lymph Nodes: Adenopathy localized or generalized lymphadenopathy. Chest: Rhonchi, crackles, dullness to percussion pneumonia. Heart: Murmurs endocarditis. Abdomen: Liver tenderness, hepatomegaly, splenomegaly. Costovertebral angle tenderness, suprapubic tenderness. Extremities: Wounds, joint or bone tenderness septic arthritis.

Needle aspiration of border for Gram's stain and culture. Antigen detection studies. Differential Diagnosis: Cellulitis, erysipelas, dermatitis, dermatophytosis. Infective Endocarditis Chief Complaint: Fever History of Present Illness: Chronic fever, murmur, malaise, anorexia, weight loss, arthralgias, abdominal pain.

Recent gastrointestinal procedure, urinary procedure, dental procedure. Past Medical History: Congenital heart disease. Physical Examination General Appearance: Note whether the patient looks toxic or well. Vital Signs: Blood pressure hypotension , pulse tachycardia , temperature fever , respirations tachypnea. Eyes: Roth spots white retinal patches with surrounding hemorrhage Chest: Crackles, rhonchi.

Heart: Regurgitant murmurs. Skin: Petechiae, Janeway lesions, Osler's nodes, splinter hemorrhages. Extremities: Edema, clubbing. Abdomen: Hepatomegaly, splenomegaly, tenderness. Neurologic: Weakness, sensory deficits. Differential Diagnosis: Infective endocarditis, rheumatic fever, systemic infection, tuberculosis, urinary tract infection.

History of Present Illness: Joint pain and warmth, redness, swelling, decreased range of motion. Acute onset of fever, limp, or refusal to walk. Penetrating injuries or lacerations. Preexisting joint disease eg, rheumatoid arthritis , prosthetic joint; sexually transmitted disease exposure.

Past Medical History: H. Vital Signs: Temperature fever , blood pressure hypotension , pulse tachycardia , respirations. Skin: Erythema, skin puncture. Vesicular rash, petechia. Chest: Crackles, rhonchi. Heart: Murmurs, friction rub. Extremities: Erythema, limitation in joint range of motion, joint tenderness, swelling. Refusal to change position. Arthrocentesis for cell count, Gram's stain, glucose, mucin clot, cultures. Bone-joint scans gallium, technetium. Blood cultures. Culture of cervix and urethra on Thayer-Martin media for gonorrhea.

Lyme titer, anti-streptolysin-O titer. Osteomyelitis Chief Complaint: Leg pain. History of Present Illness: Extremity pain, degree of fever, duration of fever, limitation of extremity use; refusal to use the extremity or bear weight. Hip pain, abdominal pain, penetrating trauma, dog or cat bite Pasteurella multocida , human bites, immunocompromise, tuberculosis. Social History: Intravenous drug abuse.

Physical Examination General Appearance: Note whether the patient looks septic or well. Skin: Petechiae, cellulitis, rash. Extremities: Point tenderness, swelling, warmth, erythema. Tenderness of femur, tibia, humerus. Back: Tenderness over spinus processes. Abdomen: Tenderness, rectal mass. Feet: Puncture wounds. Technetium bone scan.

Effect of eating, defecation, urination, movement. Characteristics of last bowel movement. Relation to last menstrual period. Relationship to meals. What does the patient do when the pain occurs? Fever, chills, nausea, vomiting bilious, undigested food, blood, sore throat, constipation, diarrhea, hematochezia, melena, anorexia, weight loss. Past Medical History: Diabetes, asthma, prematurity, surgery. Endoscopies, X-rays. Family History. Abdominal pain in family members, peptic ulcer disease, irritable bowel syndrome.

Social History: Recent travel, change in food consumption, drugs or alcohol. Review of Systems: Growth delay, weight gain, emesis, bloating, distension. Headache, fatigue, weakness, stress- or tension-related symptoms. Physical Examination General Appearance: Degree of distress, body positioning to relieve pain, nutritional status.

Signs of dehydration, septic appearance. Vitals: Temperature fever , pulse tachycardia , BP hypertension, hypotension , respiratory rate and pattern tachypnea. Skin: Jaundice, petechia, pallor, rashes. Lymph Nodes: Cervical axillary, periumbilical, inguinal lymphadenopathy, Virchow node supraclavicular mass. Abdomen Inspection: Distention, visible peristalsis small bowel obstruction. Auscultation: Absent bowel sounds late obstruction , high-pitched rushes early obstruction , bruits. Palpation: Masses, hepatomegaly, liver texture smooth, coarse , splenomegaly.

Bimanual palpation of flank, nephromegaly. Rebound tenderness, hernias, inguinal, femoral, umbilical ; costovertebral angle tenderness.

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Retained fecal material, distended bladder obstructive uropathy. McBurney's Point Tenderness: Located two-thirds of the way between umbilicus and anterior superior iliac spine appendicitis. Iliopsoas Sign: Elevation of legs against examiner's hand causes pain, retrocecal appendicitis. Obturator sign: Flexion of right thigh and external rotation of thigh causes pain in pelvic appendicitis. Rovsing's Sign: Manual pressure and release at left lower quadrant causes referred pain at McBurney's point appendicitis.

Percussion: Liver and spleen span, tympany. Rectal Examination: Impacted stool, masses, tenderness; gross or occult blood. Perianal Examination: Fissures, fistulas, hemorrhoids, skin tags, soiling fecal 42 Recurrent Abdominal Pain or urinary incontinence. Male Genital Examination: Hernias, undescended testes, hypospadias.

Female Genital Examination: Urethra, distal vagina, trauma; imperforate hymen. Pelvic examination in pubertal girls. Cervical discharge, adnexal tenderness, masses, cervical motion tenderness. Extremities: Edema, digital clubbing. Neurologic: Observation of the patient moving on and off of the examination table. Chest X-ray: Free air under diaphragm, infiltrates.

Acute Abdomen X-ray Series: Flank stripe, subdiaphragmatic free air, distended loops of bowel, sentinel loop, air fluid levels, calcifications, fecaliths. Differential Diagnosis of Acute Abdominal Pain Generalized Pain: Intestinal obstruction, diabetic ketoacidosis, constipation, malrotation of the bowel, volvulus, sickle crisis, acute porphyria, musculoskeletal trauma, psychogenic pain. Epigastrium: Gastroesophageal reflux, intestinal obstruction, gastroenteritis, gastritis, peptic ulcer disease, esophagitis, pancreatitis, perforated viscus.

Right Lower Quadrant: Appendicitis, intussusception, salpingitis, endometritis, endometriosis, ectopic pregnancy, hemorrhage or rupture of ovarian cyst, testicular torsion. Right Upper Quadrant: Appendicitis, cholecystitis, hepatitis, gastritis, gonococcal perihepatitis Fitz-Hugh-Curtis syndrome , pneumonia. Left Upper Quadrant: Gastroesophageal reflux, peptic ulcer, gastritis, pneumonia, pancreatitis, volvulus, intussusception, sickle crisis. Left Lower Quadrant: Volvulus, intussusception, mesenteric lymphadenitis, intestinal obstruction, sickle crisis, colitis, strangulated hernia, testicular torsion, psychogenic pain, inflammatory bowel disease, gastroenteritis, pyelonephritis, salpingitis, ovarian cyst, ectopic pregnancy, endometriosis.

History of Present Illness: Quality of pain burning, crampy, sharp, dull ; location diffuse or localized. Duration of pain, change in frequency; constant or intermittent. Effect of eating, vomiting, defecation, urination, inspiration, movement and position. Characteristics of bowel movements.

Vomiting bilious, undigested food, blood , constipation, diarrhea, hematochezia, melena; dysuria, hematuria, anorexia, weight loss. Relationship to the menstrual cycle. How does it affect activity? School attendance, school stress, school phobia. What fears does the child have? What activities has the child discontinued? Past Testing: Endoscopies, x-rays, upper GI series. Prior treatment for a abdominal pain. Family History: Abdominal pain in family members, urolithiasis, migraine, peptic ulcer disease, irritable bowel syndrome, hemolytic anemia, chronic pain.

Social History: Recent travel, change in schools, change in water and food consumption, marital discord, recent losses grandparent, pet , general family function. Review of Systems: Growth, weight gain, stool pattern, bloating, distension, hematemesis, hematochezia, jaundice.

Headache, limb pain, dizziness, fatigue, weakness. Stress- or tension-related symptoms. Physical Examination General Appearance: Degree of distress, septic appearance. Vitals: Temperature fever , pulse tachycardia , BP hypertension, hypotension , respiratory rate tachypnea. Growth percentiles, deceleration in growth, weight-for-height. Skin: Pallor, rashes, nodules, jaundice, purpura, petechia.

Lymph Nodes: Cervical, periumbilical, inguinal lymphadenopathy, Virchow node enlarged supraclavicular node. Chest: Breath sounds, rhonchi, wheeze. Heart: Murmurs, distant heart sounds, peripheral pulses. Abdomen Inspection: Abdominal distention, scars, visible peristalsis.

Auscultation: Quality and pattern of bowel sounds; high-pitched bowel sounds partial obstruction , bruits. Palpation: Palpation while noting the patient's appearance, reaction, and distractibility. Tenderness, rebound, masses, hepatomegaly; liver texture smooth, coarse , splenomegaly; retained fecal material.

Bimanual palpation of flank nephromegaly , hernias inguinal, femoral, umbilical ; costovertebral angle tenderness. McBurney's point tenderness: Located two thirds of the way between umbilicus and anterior superior iliac spine, appendicitis. Rovsing's sign: Manual pressure and release at left lower quadrant causes referred pain at McBurney's point, appendicitis. Percussion: Tympany, liver and spleen span by percussion.

Perianal Examination: Fissures, fistulas, hemorrhoids, skin tags, underwear soiling fecal or urinary incontinence. Female Genital Examination: Hymeneal ring trauma, imperforate hymen, urethra, distal vagina. Extremities: Brachial pulses, femoral pulses, edema. Digital clubbing, loss of nailbed angle osteoarthropathy. Neurologic Examination: Observation of the patient moving on and off of the examination table; gait. X-rays of Abdomen acute abdomen series : Flank stripe, subdiaphragmatic free air, distended loops of bowel, air fluid levels, mass effects, calcifications, fecaliths.

History of Present Illness: Character of emesis effortless, forceful, projectile, color, food, uncurdled milk, bilious, feculent, blood, coffee ground material ; abdominal pain, retching, fever, headache, cough. Jaundice, recent change in medications. Ingestion of spoiled food; exposure to ill contacts. Overfeeding, weight and growth parameters, vigorous hand or finger sucking, maternal polyhydramnios. Wheezing, irritability, apnea. Pain on swallowing odynophagia , difficulty swallowing dysphagia. Diarrhea, constipation. Proper formula preparation, air gulping, postcibal handling.

Constant headache, worse with Valsalva maneuver and occurring with morning emesis increased ICP. Possibility of pregnancy last menstrual period, contraception, sexual history. Prior X-rays, upper GI series, endoscopy. Travel, animal or pet exposure. Medications: Digoxin, theophylline, chemotherapy, anticholinergics, morphine, ergotamines, oral contraceptives, progesterone, erythromycin.

Family History: Migraine headaches. Vital Signs: BP hypotension, hypertension , pulse tachycardia , respiratory rate, temperature fever. Skin: Pallor, jaundice, flushing, rash. HEENT: Nystagmus, papilledema; ketone odor on breath apple odor, diabetic ketoacidosis ; jugular venous distention. Bulging fontanelle, papilledema. Lungs: Wheezes, rhonchi, rales. Abdomen: Tenderness to percussion, distention, increased bowel sounds, rebound tenderness peritonitis.

Nephromegaly, masses, hepatomegaly, splenomegaly, costovertebral angle tenderness. Extremities: Edema, cyanosis. Genitourinary: Adnexal tenderness, uterine enlargement. Rectal: Perirectal lesions, localized tenderness, masses, occult blood. Neurologic Examination: Strength, sensation, posture, gait, deep tendon reflexes. History of Present Illness: Timing, progression, distribution of jaundice. Abdominal pain, anorexia, vomiting, fever, dark urine, pruritus, arthralgias, rash, diarrhea. Gradual, caudal progression of jaundice physiologic jaundice or breast-feeding jaundice , blood products, raw shellfish, day care centers, foreign travel.

Past Medical History: Hepatitis serologies, liver function tests, liver biopsy, hepatitis immunization. Perinatal History: Course of the pregnancy, illnesses, infections, medications taken during the pregnancy.

Oliver Dorigo, M.D., Ph.D.

Inability to pass meconium cystic fibrosis , failure to thrive, irritability. Newborn hypoglycemia, lethargy after the first formula feedings carbohydrate metabolic disorders. Medications: Acetaminophen, isoniazid, phenytoin. Family History: Liver disease, familial jaundice, lung disease, alpha1-antitrypsin deficiency. History of perinatal infant death metabolic disorders. Social History: IV drug abuse, alcohol, exposure to hepatitis.

Acute illness Failure to thrive Family history of jaundice Exposure: Blood products, raw shellfish, travel, drug abuse Physical Examination General Appearance: Signs of dehydration, septic appearance, irritability. Vital Signs: Pulse, BP, respiratory rate, temperature fever. Skin: Ecchymoses, excoriations, jaundice, urticaria, bronze discoloration hemochromatosis , diffuse rash perinatal infection.

Malar rash, discord lesions lupus , erythematous scaling papules cystic fibrosis. Lymph Nodes: Cervical or inguinal lymphadenopathy. Head: Cephalohematoma, hypertelorism, high forehead, large fontanelle, pursed lips Zellweger syndrome , microcephaly. Eyes: Scleral icterus, cataracts, Kayser-Fleischer rings bronze corneal pigmentation, Wilson's disease , xanthomas chronic liver disease. Mouth: Sublingual jaundice. Chest: Gynecomastia, breath sounds. Abdomen: Bowel sounds, bruits, right upper quadrant tenderness; liver span, hepatomegaly; liver margin texture blunt, irregular, firm, smooth , splenomegaly; ascites.

Extremities: Joint tenderness, joint swelling, palmar erythema, edema, anasarca. Jaundice, erythematous nodules over shins erythema nodosum. Neurologic: Lethargy, hypotonia, neuromuscular deficits. Rectal: Perianal skin tags inflammatory bowel disease , hemorrhoids, occult blood. History of Present Illness: Duration of enlargement of the liver or spleen. Acute or chronic illness, fever, jaundice, pallor, bruising, weight loss, fatigue, joint pain, joint stiffness. Nutritional history, growth delay. Neurodevelopmental delay or loss of developmental milestones.

Past Medical History: Previous organomegaly, neurologic symptoms. General health.

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Perinatal History: Prenatal complications, neonatal jaundice. Medications: Current and past drugs, anticonvulsants, toxins. History of neonatal death. Social History: Infections, toxin, exposures, drugs or alcohol. Physical Examination General Appearance: Wasting, ill appearance, malnutrition. Vital Signs: Blood pressure, temperature, pulse, respirations. Growth curve. Coarsening of facial features mucopolysaccharidoses. Skin: Excoriations, spider angiomas chronic liver disease, bilary obstruction of the biliary tract ; pallor, petechiae, bruising malignancy, chronic liver disease ; erythema nodosum inflammatory bowel disease, sarcoidosis.

Lymph Nodes: Location and size of lymphadenopathy. Lungs: Crackles, wheeze, rhonchi. Percussion of flanks for shifting dullness. Liver span by Hepatosplenomegaly 53 percussion, hepatomegaly. Liver consistency and texture. Spleen size and texture, splenomegaly. Perianal: Hemorrhoids portal hypertension , fissures, skin tags, fistulas inflammatory bowel disease. Rectal Exam: Masses, tenderness. Extremities: Edema, joint tenderness, joint swelling, joint erythema juvenile rheumatoid arthritis, mucopolysaccharidoses.

Clubbing hypoxia, intestinal disorders, hepatic disorders. History of Present Illness: Duration and frequency, of diarrhea; number of stools per day, characteristics of stools bloody, mucus, watery, formed, oily, foul odor ; fever, abdominal pain or cramps, flatulence, anorexia, vomiting. Season rotavirus occurs in the winter. Amount of fluid intake and food intake. Past Medical History: Recent ingestion of spoiled poultry salmonella , spoiled milk, seafood shrimp, shellfish; Vibrio parahaemolyticus ; common food sources restaurants , travel history. Ill contacts with diarrhea, sexual exposures.

Family History: Coeliac disease. Medications Associated with Diarrhea: Magnesium-containing antacids, laxatives, antibiotics. Immunizations: Rotavirus immunization. Physical Examination General Appearance: Signs of dehydration. Note whether the patient looks septic, well, or malnourished. Skin: Turgor, delayed capillary refill, jaundice. Heart: Rhythm, gallops, murmurs. Abdomen: Distention, high-pitched rushes, tenderness, splenomegaly, hepatomegaly. Extremities: Joint swelling, edema.

Rectal: Sphincter tone, guaiac test. Gram's stain of stool for leukocytes. Cultures for enteric pathogens, stool for ova and parasites x 3; stool and blood for clostridium difficile toxin; blood cultures. Stool occult blood. Stool cultures for cholera, E. Chronic Diarrhea Chief Complaint: Diarrhea. History of Present Illness: Duration, frequency, and timing of diarrheal episodes. Volume of stool output number of stools per day.

Effect of fasting on diarrhea. Prior dietary manipulations and their effect on stooling. Formula changes, fever, abdominal pain, flatulence, tenesmus painful urge to defecate , anorexia, vomiting, myalgias, arthralgias, weight loss, rashes. Stool Appearance: Watery, formed, blood or mucus, oily, foul odor. Travel history, laxative abuse, inflammatory bowel disease. Sexual exposures, AIDS risk factors. Exacerbation by stress.

Past Medical History: Pattern of stooling from birth. Growth deficiency, weight Chronic Diarrhea 55 gain. Three-day dietary record, ill contacts. Medications and Substances Associated with Diarrhea: Laxatives, magnesium-containing antacids, cholinergic agents, milk lactase deficiency , gum sorbitol. Family History: Family members with diarrhea, milk intolerance, coeliac disease. Social History: Water supply, meal preparation, sanitation, pet or animal exposures. Septic appearance. Skin: Turgor, delayed capillary refill, jaundice, pallor anemia , hair thinning, rashes, erythema nodosum, pyoderma gangrenosum, maculopapular rashes inflammatory bowel disease , hyperpigmentation adrenal insufficiency.

Eyes: Bitot spots vitamin A deficiency , adenopathy. Mouth: Oral ulcers Crohn disease, coeliac disease , dry mucous membranes; cheilosis cracked lips, riboflavin deficiency ; glossitis B12, folate deficiency ; oropharyngeal candidiasis AIDS. Lymph Nodes: Cervical, axillary, inguinal lymphadenopathy. Chest: Thoracic shape, crackles, wheezing. Abdomen: Distention malnutrition , hyperactive, bowel sounds, tenderness, masses, palpable bowel loops, palpable stool. Hepatomegaly, splenomegaly. Extremities: Joint tenderness, swelling ulcerative colitis ; gluteal wasting malnutrition , dependent edema.

Genitalia: Signs of child abuse or sexual activity. Perianal Examination: Skin tags and fistulas. Rectal: Perianal or rectal ulcers, sphincter tone, tenderness, masses, impacted stool, occult blood, sphincter reflex. Neurologic: Mental status changes, peripheral neuropathy B6, B12 deficiency , decreased perianal sensation. Ataxia, diminished deep tendon reflexes, decreased proprioception. Wright's stain for fecal leucocytes; cultures for enteric pathogens, ova and parasites x 3; clostridium difficile toxin. Stool carbohydrate content. Stool for occult blood, neutral fat maldigestion ; split fat malabsorption.

History of Present Illness: Stool frequency, consistency, size; stooling pattern birth to the present. Encopresis, bulky, fatty stools, foul odor. Hard stools, painful defecation, straining, streaks of blood on stools. Dehydration, urinary incontinence, enuresis. Abdominal pain, fever. Recent change in diet. Soiling characteristics and time of day. Are stools formed or scybalous small, dry, rabbit-like pellets? Withholding behavior. Past Medical History: Recent illness, bed rest, fever. Social History: Recent birth of a sibling, emotional stress, housing move.

Family History: Constipation. Physical Examination General Appearance: Dehydration or malnutrition. Septic appearance, weak cry. Vital Signs: BP hypertension, pheochromocytoma , pulse, respiratory rate, temperature. Growth percentiles, poor growth. Eyes: Decreased pupillary response, icterus. Mouth: Cheilosis cracked lips, riboflavin deficiency , oral ulcers inflammatory bowel, coeliac disease , dry mucous membranes, glossitis B12, folate deficiency , oropharyngeal candidiasis AIDS.

Abdomen: Distention, peristaltic waves, weak abdominal musculature muscular dystrophy, prune-belly syndrome. Hyperactive bowel sounds, tenderness, hepatomegaly. Palpable stool, fecal masses above the pubic symphysis and in the left lower quadrant. Perianal: Anterior ectopic anus, anterior anal displacement. Rectal prolapse. Soiling in the perianal area. Sphincter reflex: Gentle rubbing of the perianal skin results in reflex contraction of the external anal sphincter.

Rectal: Sphincter tone, rectal ulcers, tenderness, hemorrhoids, masses. Stool in a cavernous ampulla, occult blood. Extremities: Joint tenderness, joint swelling ulcerative colitis. Neurologic: Developmental delay, mental retardation, peripheral neuropathy B6, B12 deficiency , decreased perianal sensation. Abdominal X-ray: Air fluid levels, dilation, pancreatic calcifications.

Forceful retching prior to hematemesis Mallory-Weiss tear. Hematemesis and Upper Gastrointestinal Bleeding 59 Abdominal pain, melena, hematochezia; peptic ulcer, prior bleeding episodes, nose bleeds. Weight loss, anorexia, jaundice; bright red foods, drinks. Past Medical History: Diabetes, bleeding disorders, renal failure, liver disease. Gastrointestinal surgery. Physical Examination General Appearance: Pallor, diaphoresis, confusion, dehydration. Skin: Delayed capillary refill, pallor, petechiae. Hemorrhagic telangiectasia Osler-Weber-Rendu syndrome , abnormal pigmentation Peutz-Jeghers syndrome , jaundice, ecchymoses coagulopathy , increased skin elasticity Ehlers-Danlos syndrome.

Eyes: Scleral pallor. Heart: Systolic ejection murmur. Abdomen: Dilated abdominal veins, bowel sounds, distention, tenderness, masses, hepatic atrophy, splenomegaly.


Extremities: Edema, cold extremities. Neurologic: Decreased mental status, gait. Rectal: Masses, hemorrhoids. Polyps, fissures; stool color, occult blood testing. Type and cross-match for units of packed RBC and transfuse as needed. Esophagogastroduodenoscopy, colonoscopy, Meckel's scan, bleeding scan.

Change in bowel habits, change in stool caliber, abdominal pain, fever. Constipation, diarrhea, anorectal pain. Epistaxis, anorexia, weight loss, malaise, vomiting. Fecal mucus, excessive straining during defecation. Colitis, peptic ulcer, hematemesis. Physical Examination General Appearance: Dehydration, pallor. Note whether the patient looks ill, well, or malnourished. Vital Signs: BP orthostatic hypotension , pulse, respiratory rate, temperature tachycardia. Skin: Delayed capillary refill, pallor, jaundice. Spider angiomata, rashes, purpura. Eyes: Pale conjunctiva, icterus.

Heart: Systolic ejection murmurs. Abdomen: Masses, distention, tenderness, hernias, liver atrophy, splenomegaly. Genitourinary: Testicular atrophy. Extremities: Cold, pale extremities. Neurologic: Anxiety, confusion. Rectal: Hemorrhoids, masses; fissures, polyps, ulcers. Gross or occult blood. Laboratory Evaluation: CBC anemia , liver function tests. Abdominal x-ray series thumbprinting, air fluid levels. History of Present Illness: Date of last menstrual period. Primary amenorrhea absence of menses by age 16 or secondary amenorrhea cessation of menses after previously normal menstruation.

Age of menarche, menstrual regularity; age of breast development; sexual activity, possibility of pregnancy, pregnancy testing. Symptoms of pregnancy nausea, breast tenderness. Lifestyle changes, dieting, excessive exercise, drugs marijuana , psychologic stress. Hot flushes hypoestrogenism , galactorrhea prolactinoma. Weight loss or gain, headaches, vision changes. Medications: Contraceptives, tricyclic antidepressants, digoxin, marijuana, chemotherapeutic agents. Physical Examination General Appearance: Secondary sexual characteristics, body habitus, obesity, deep voice hyperandrogenism.

Vital Signs: Pulse bradycardia , temperature hypothermia, hypothyroidism , blood pressure, respirations. Skin: Acne, hirsutism, temporal balding hyperandrogenism, cool dry skin hypothyroidism. Eyes: Visual field defects, bitemporal hemianopsia pituitary adenoma. Neck: Thyroid enlargement or nodules. Chest: Galactorrhea, impaired breast development, breast atrophy. Heart: Bradycardia hypothyroidism. Extremities: Tremor hyperthyroidism. Neurologic: Focal motor deficits.

Progesterone challenge test. History of Present Illness: Last menstrual period, number of soaked pads per day; menstrual regularity, age of menarche, duration and frequency of menses; passing of clots; postcoital or intermenstrual bleeding; abdominal pain, fever, lightheadedness; possibility of pregnancy, sexual activity, hormonal contraception. Psychologic stress, weight changes, exercise. Changes in hair or skin texture. Past Medical History: Obstetrical history. Thyroid, renal, or hepatic disease; coagulopathies, endometriosis, dental bleeding.

Family History: Coagulopathies, endocrine disorders. Physical Examination General Appearance: General body habitus, obesity. Vital Signs: Assess hemodynamic stability, tachycardia, hypotension, orthostatic vitals; signs of shock. Skin: Pallor, hirsutism, petechiae, skin texture; fine thinning hair hypothyroidism. Neck: Thyroid enlargement. Breasts: Masses, galactorrhea. Gyn: Cervical motion tenderness, adnexal tenderness, uterine size, cervical lesions. Endometrial biopsy. Differential Diagnosis of Abnormal Vaginal Bleeding: Chronic anovulation, pelvic inflammatory disease, cervicitis, pregnancy ectopic pregnancy, spontaneous abortion, molar pregnancy.

Hyperthyroidism, hypothyroidism, adrenal disease, diabetes mellitus. Hyperprolactinemia, polycystic ovary syndrome, oral contraceptives, medroxyprogesterone, anticoagulants, NSAIDs. Cervical polyps, uterine myoma endometriosis, retained tampon, trauma, Von Willebrand's disease. History of Present Illness: Pelvic or abdominal pain bilateral or unilateral , positive pregnancy test, missed menstrual period, abnormal vaginal bleeding quantify. Date of last menstrual period. Fever or vaginal discharge. Past Medical History: Surgical history, sexually transmitted diseases, Chlamydia, gonorrhea, obstetrical history.

Prior pelvic infection, endometriosis, prior ectopic pregnancy, pelvic tumor, intrauterine device. Medications: Oral contraceptives. Physical Examination General Appearance: Moderate or severe distress. Vital Signs: BP orthostatic hypotension , pulse tachycardia , respiratory rate tachypnea , temperature low fever. Skin: Cold skin, pallor, delayed capillary refill.

Abdomen: Cullen's sign periumbilical darkening, intraabdominal bleeding , local then generalized tenderness, rebound tenderness. Pelvic: Cervical discharge, cervical motion tenderness; Chadwick's sign cervical cyanosis, pregnancy ; Hegar's sign softening of uterine isthmus, pregnancy ; enlarged uterus, adnexal tenderness, cul-de-sac fullness.

Differential Diagnosis of Pelvic Pain Pregnancy-Related Causes: Ectopic pregnancy, spontaneous abortion, threatened abortion, incomplete abortion, intrauterine pregnancy with corpus luteum bleeding. Gynecologic Disorders: Pelvic inflammatory disease, endometriosis, ovarian cyst hemorrhage or rupture, adnexal torsion, Mittelschmerz, primary dysmenorrhea, tumor. Nonreproductive Causes of Pelvic Pain Gastrointestinal: Appendicitis, inflammatory bowel disease, mesenteric adenitis, irritable bowel syndrome.

Urinary Tract: Urinary tract infection, renal calculus. Increasing frequency. Progression in severity. Does the headache interfere with normal activity or cause the child to stop playing? Awakening from sleep; analgesic use. Aura or Prodrome: Visual scotomata, blurred vision; nausea, vomiting, sensory disturbances. Associated Symptoms: Numbness, weakness, diplopia, photophobia, fever, nasal discharge sinusitis , neck stiffness meningitis. Aggravating or Relieving Factors: Relief by analgesics or sleep. Exacerbation by light or sounds, straining, exercising, or changing position.

Exacerbation by foods cheese , emotional upset, menses. Past Medical History: Growth delay, development delay, allergies, past illnesses. Head injuries, motion sickness. Anxiety or depression Medications: Dosage, frequency of use, and effect of medications. Birth control pills. Family History: Migraine headaches in parents. Parental description of their headaches. Social History: School absences. Stressful events.

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Emotional problems at home or in school. Cigarettes, alcohol, illegal drugs. Review Systems: Changes in personality, memory, intellectual skills, vision, hearing, strength, gait, or balance. Postural lightheadedness, weakness, vertigo. Vital Signs: BP hypertension , pulse, temperature fever , respiratory rate. Height, weight, head circumference; growth percentiles. Weight loss, lack of linear growth. Skin: Pallor, petechiae, bruises.

Alopecia, rashes, and painless oral ulcers. Facial angiofibromas adenoma sebaceum. Head: Macrocephaly, cranial tenderness, temporal tenderness. Dilated scalp veins, frontal bossing. Sinuses tenderness sinusitis to percussion, temporal bruits arteriovenous malformation. Eyes: Downward deviation of the eyes "sunset-ring" increased intracranial pressure , extraocular movements, pupil reactivity; papilledema, visual field deficits. Conjunctival injection, lacrimation cluster headache.

Nose: Rhinorrhea cluster headache. Mouth: Tooth tenderness, gingivitis, pharyngeal erythema. Masseter muscle spasm, restricted jaw opening TMJ dysfunction. Neck: Rigidity, neck muscle tenderness. Neurologic Examination: Mental status, cranial nerve function, motor strength, sensation, deep tendon reflexes. Disorientation, memory impairment, extraocular muscle dysfunction, spasticity, hyperreflexia, clonus, Babinski sign, ataxia, coordination. Past seizures, noncompliance with anticonvulsant medication.

Aura before seizure irritability, behavioral change, lethargy , incontinence of urine or feces, post-ictal weakness or paralysis, injuries. Can the patient tell when an episode will start? Warning signs, triggers for the spells crying, anger, boredom, anxiety, fever, trauma. Does he speak during the spell? Does the child remember the spells afterward? What is the child like after the episode confused, alert? Can the child describe what happens? Past Medical History: Illnesses, hospitalizations, previous functioning, rheumatic fever.

Electroencephalograms, CT scans. Medications: Antidepressants, stimulants, antiseizure medications. Family History: Similar episodes in family, epilepsy, migraine, tics, tremors, Tourette syndrome, sleep disturbance. Note whether the patient looks well or ill. Observe the patient performing tasks tying shoes, walking. Vital Signs: Growth percentiles, BP hypertension , pulse, respiratory rate, temperature hyperpyrexia. Unilateral port-wine facial nevus Sturge-Weber syndrome ; facial angiofibromas adenoma sebaceum , hypopigmented ash leaf spots tuberous sclerosis.

HEENT: Head trauma, pupil reactivity and equality, extraocular movements; papilledema, gum hyperplasia phenytoin ; tongue or buccal lacerations; neck rigidity. Chest: Rhonchi, wheeze aspiration. Extremities: Cyanosis, fractures, trauma. Perianal: Incontinence of urine or feces. Neuro: Dysarthria, visual field deficits, cranial nerve palsies, sensory deficits, focal weakness Todd's paralysis , Babinski's sign, developmental delay. History of Present Illness: Length of pause in respiration. Change in skin color cyanosis, pallor , hypotonia or hypertonia, resuscitative efforts rescue breaths, chest compressions.

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Stridor, wheezing, body position during the event, state of consciousness before, during and after the event. Unusual movements, incontinence, postictal confusional state. Regurgitation after feedings. Vomitus in oral cavity during the event. Medications accessible to the child in the home. Past Medical History: Abnormal growth, developmental delay, asthma. Perinatal History: Prenatal exposure to infectious agents, maternal exposure to opioids, difficulties during labor and delivery.

Respiratory difficulties after birth. Immunizations: Pertussis. Social history: Physical abuse, previous involvement of the family with child protective services.