Which essential questions will you ask a pediatric patient or his or her caregiver when the presenting complaint is bloody diarrhea? Will these questions vary depending upon the child’s age? Why or why not? What clinical or historical findings will indicate the need for diagnostic studies and why? Which diagnostic studies will you initially order and why?
When a pediatric patient presents with bloody diarrhea, the provider need to ask certain questions to investigate the problem and reach to a point where differential diagnosis can be made and tests can be suggested for the patient. I would ask the following questions from the caregiver for pediatric patient suffering from bloody diarrhea
• When did the bloody diarrhea start?
• Does your child has vomiting?
• Does the child has fever?
• How many episodes of bloody diarrhea child has?
• Are there any other symptoms that the child is showing?
• Has the child eaten something inappropriate?
• Is the child’s immunization’s up-to-date?
• Does anyone in the family has similar diarrhea?
• Did the child had interaction with a sick person?
• Is the child taking any prescription medicine?
• Is the child taking any over-the-counter medicine?
• What is the color of blood, is it bright red or dark red or black in color?
The above mentioned questions are general questions and I would ask the above mentioned question for a child of any age presenting with the problem of bloody diarrhea. However, I would also include questions to evaluate probability of intussusception in the child. Intussusception is a common cause of intestinal obstruction in children 3 months to 6-years, old and lead to symptoms of vomiting and bloody mucous stools (Burns, Dunn, Brady, Starr, & Blosser, 2016). I would ask the following questions to evaluate of child’s problem is because of intussusception:
• Does the stool have a currant jelly like appearance?
• Does the child report abdominal pain?
• Does the child seems to be lethargic?
For a child having bloody diarrhea, certain test would be needed to diagnose the problem and initiate the treatment. Following test would be needed for the child who has bloody diarrhea:
• Rectal and fecal occult
• Stool culture and stool pH (Willer et al., 2016)
Following additional test would also be needed for the patient:
• CBC
• ESR
• CMP
• C-reactive (Burns, Dunn, Brady, Starr, & Blosser, 2016)
What would be three differential diagnoses in this case?
Following are the three differential diagnosis for the child in iHuman case:
• Gastroenteritis (viral, parasitic, or bacterial): signs and symptoms of the condition include vomiting, abdominal pain, and high volume watery stool (Burns et al., 2016; Hartman, Brown, Loomis, & Russell, 2019)). Patient’s mother reported that she had vomiting and diarrhea.
• Dehydration: Child has been having vomiting and diarrhea for the past two days. Fluid loss during these conditions can lead to dehydration (Burns et al., 2016; Caruggi, et al., 2018).
• Appendicitis: nausea and vomiting are symptoms present during appendicitis followed by abdominal pain. Diarrhea is however not reported in most patients (Burns, Dunn, Brady, Starr, & Blosser, 2016).
How do the common causes of vomiting differ in infants, children, and adolescents? What clinical or historical findings will indicate the need for diagnostic studies and why? Which diagnostic studies will you initially order and why?
Vomiting in infants and newborns may occur because of following reasons:
• Infection
• GI or CNS abnormality
• Inborn error or metabolism
Vomiting in infant and young children may be a symptoms of food allergy, GERD, gastroenteritis or intussusception, or an intracranial mass. In older children and adolescents, vomiting may indicate CNS abnormality, systemic illness, intussusception, or gastroenteritis (Willer et al., 2017). During client’s assessment, the findings that may indicate the need for diagnostic testing include:
• Early morning vomiting
• Blood in vomiting
• Relationship to meals
• Associated condition in a family such as family history of GI disease
• Associated symptoms such as abdominal pain, respiratory issues etc (Willer et al., 2017).
Laboratory studies to assess condition depends upon the differential diagnosis. Common laboratory test needed to evaluate if patient has bacterial, inflammatory or serious complications include:
• Blood culture
• CBC with differentials
• CRP
• ESR
• CMP
• UA
• Stool culture
Diagnostic imaging may be need if test results are not helpful to confirm the diagnosis. Diagnostic studies include abdominal x-rays, ultrasounds, barium swallows and CT scans
References
Burns, C., Dunn, A., Brady, M., Starr, N., & Blosser, C. (2016). Pediatric primary care: A handbook for nurse practitioners (6th ed.). Philadelphia: Saunders.
Caruggi, S., Rossi, M., De Giacomo, C., Luini, C., Ruggiero, N., Salvatoni, A., & Salvatore, S. (2018). Pediatric dehydration assessment at triage: Prospective study on refilling time. Pediatric gastroenterology, hepatology & nutrition, 21(4), 278-288.
Hartman, S., Brown, E., Loomis, E., & Russell, H. A. (2019). Gastroenteritis in children. American Family Physician, 66(3), 159-165. Retrieved from https://www.aafp.org/afp/2019/0201/p159.html
Willer, E., James-Petersen, B., & Petersen-Smith, A. (2016). Chapter 33: Gastrointestinal disorders. In C. E. Burns, A. M. Dunn, M. A. Brady, N. B. Starr, C. G. Blosser, D. L. Garzon, & N. M. Gaylord, Pediatric primary care (pp. 833-840). 6th.