Pediatric emergency medicine trisk 0935 0935

weight loss, night sweats, arthralgias, rashes, and bruising or petechiae that may suggest
underlying systemic pathology and prompt more aggressive evaluation.
Social history and ill contacts of children also provide important information in
constructing a differential diagnosis. Ill contacts of children at school or in the home,
particularly affected by viral respiratory infections, infectious mononucleosis, or group A
streptococcus infections, should be noted. Inquiry about a child’s close contacts with a
diagnosis of tuberculosis, symptoms of active disease, travel, or risk factors for
acquisition is imperative when considering tuberculous adenitis. Asking about pets (cats
or fish tanks), residence (exposure to livestock), recent travel or outdoor activity (animal
exposure and insect bites), and dietary patterns (consumption of unpasteurized milk or
cheese, or undercooked meats) can provide key information in a given clinical context.
Finally, the clinician must ask about medication use and whether any prior treatment,
such as antibiotic therapy, treatment with glucocorticoids, or attempted aspiration with
cultures, has been initiated. For example, children with NTM adenitis or Kawasaki
disease may present to the emergency department after a course of antistaphylococcal
antibiotic therapy failed to reduce the size of the node. This information can often guide
the physician to include or exclude certain diagnoses. The importance of avoiding
glucocorticoids prior to making a definitive diagnosis of the cause of lymphadenopathy
should be emphasized. Glucocorticoid treatment can mask or delay the histologic
diagnosis of malignancy such as leukemia or lymphoma, and should not be given
empirically to decrease node swelling.
The physical examination should include a careful measurement of the size of the
enlarged nodes and documentation of the number of nodes involved to provide an
adequate baseline for follow-up. Describing a node’s consistency (soft, firm, rubbery,
indurated, fluctuant), mobility (mobile or fixed), and degree of tenderness to palpation is
essential. Skin changes around the node (erythematous and edematous, or violaceous and
paper-thin) should be noted. Lymphadenopathy in any region should prompt examination
of lymph nodes in all regions to assess for generalized involvement. Finally, a complete
physical examination noting rashes, hepatosplenomegaly, joint swelling, or other
abnormalities is critical.
In well-appearing children without systemic symptoms, further evaluation of acute

localized lymphadenopathy is generally unnecessary. Children with symptoms of
lymphadenitis (a unilateral node with erythema, edema, or tenderness) can be empirically
treated with a 10- to 14-day course of antibiotics with MRSA coverage and reevaluated.
There are several predictors for a suppurative adenitis that may require surgical drainage.
These can be independently used in the decision-making process for diagnostic imaging
and surgical consultation; absence of pharyngitis, age ≤3 years, WBC >15,000/mm3, and
anterior cervical chain location. Children without symptoms of an acute bacterial
lymphadenitis can be observed over the same time course, provided they have no
enlargement of the adenopathy and lack worrisome constitutional symptoms. Reactive
adenopathy that occurs after a viral illness typically resolved within 2 to 3 weeks.