What are the Clinical Differences Between Acute Paronychia and Herpetic Whitlow?

Patient Presentation
A 3-year-old female came to clinic with a rash around her mouth and on her finger. She had 3 days of fever and some drooling with decreased appetite and had complained of a sore throat. Her mother noticed red, blister-like lesions in clusters near the right upper lip, that began the evening before. That morning the mother noticed her right index finger was red and generally swollen. This was the same finger she sucked. The mother denied upper respiratory illnesses or ear pain and the child had been drinking and urinating well. The past medical history showed her to be previously well.

The pertinent physical exam revealed a tired but interactive child with a temperature of 38.6°C and normal vital signs. Her growth parameters were 50-75%. By her upper lip she had 5 clustered vesicular lesions (2-4 mm in size) with an erythematous base and clear fluid. It appeared that she was also developing another area on the left corner of the mouth. There was generalized erythema of the pharynx and one ulceration of the inner lower lip. The HEENT examination showed shoddy anterior cervical adenopathy but the rest of the examination was normal including her eyes. The proximal interphalyngeal joint to the tip of the index finger was generally red and slightly edematous. There were 2 clustered, flat lesions with clearish-yellow fluid in them with a surrounding erythema next to the base of the fingernail. The rest of her examination was normal.

The diagnosis of herpes labialis and herpetic whitlow was made. The child was begun on acyclovir. The patient’s clinical course showed when she returned for followup the next day that the right-sided lip lesions appeared to be stable, and there was no left sided lesion. The lesions on her finger were decreasing slightly in size and the finger was slightly less edematous. It was still erythematous but the erythema had not spread. Her mother said she was complaining of pain in her mouth and hand but it was controlled with ibuprofen. She had no other lesions include a negative eye examination. On telephone followup the next day, her mother said that the right lip lesion was decreasing and her finger was now only pink in color with the lesions appearing “improved.” Her fever had also resolved and she was eating soft food without problems.

Discussion
Primary herpes simplex virus (HSV) infection usually shows symptoms 2-20 days after contact. The virus enters the skin or mucous membranes and may then enter the dorsal root gangilons and become latent only to reactivate months to years in the future. Humans are the only known host. Recurrent infections may be caused by various stresses, including mental stress, fever, temperature extremes, sun or ultraviolet light exposure, trauma and immunosupression. HSV-1 usually causes gingivosomatitis and usually enters the trigeminal neuron. HSV-2 usually causes herpes genitalis and enters the sacral nerves. Primary oral HSV-1 usually has fever, with mouth lesions occurring and cervical and submandibular lymphadenopathy

In primary oral HSV-1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. Other recognized forms of herpes include herpes gladiatorum where lesions occur on the skin in wrestlers, and herpetic sycosis, where lesions occur in the beard area due to autoinnoculation from shaving, or direct spread.

Learning Point
Herpetic whitlow has vesicular, clear to yellow lesions with an erythematous base on the fingers or hands that occurs in children who suck their hands. It can also occur in healthcare workers exposed when not wearing gloves. In children whitlow is caused almost exclusively by HSV-1 but in adults may be caused by HSV-1 or HSV-2. Direct transmission from saliva to the hand causes whitlow, although patients may be unaware that they are shedding virus and only present with whitlow. Vesicles are clear or pale yellow and have an erythematous base. The lesions may spread around and under the nail. Satellite lesions may occur in the first two weeks. Whitlow is treated with acyclovir and not incision and drainage. If not treated, herpetic whitlow resolves in about 3 weeks.

Acute paronychia and periungual felon may look like herpetic whitlow. They are caused by bacteria and usually appear with opaque, purulent fluid along the nail bed, and often will have surrounding erythema. The pressure may increase because of the paronychia and therefore incision and drainage is necessary, along with antibiotics.

Viral culture is the most sensitive test for herpetic whitlow but Tzank smear with multinucleated giant cells can be positive in 50-60% of cases. Tzank is not specific for herpes but can also be positive in varicella.

Questions for Further Discussion
1. What are the potential complications of herpetic whitlow?
2. What are the possible problems with a neonate or immunocompromized person who contracts HSV?
3. What is the treatment for herpes ocularis?
4. what is the treatment for herpes genitalis?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Hand Injuries and Disorders and Herpes Simplex.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010 Nov 1;82(9):1075-82.

Rubright JH, Shafritz AB. The herpetic whitlow. J Hand Surg Am. 2011 Feb;36(2):340-2.

Richert B, Andre´ J. Nail disorders in children: diagnosis and management. Am J Clin Dermatol. 2011 Apr 1;12(2):101-12.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Many Children Live with Their Grandparents?

    Patient Presentation
    A 6-year-old female came to clinic who was well-known to the practice for a fever and earache for 1 day. She previously had rhinorrhea for 3 days, and was otherwise well. The past medical history was non-contributory. The pertinent physical exam showed a healthy female with temperature of 39.4°C with other vital signs and growth parameters normal. She had copious clear rhinorrhea, slightly erythematous pharynx and a left ear with erythema, pus and immobile tympanic membrane. The right ear had a splayed light reflex and opaque fluid behind the tympanic membrane with a fluid level. The diagnosis of left otitis media was made. The grandmother remarked that she was now happier because she had recently gained legal custody of the girl and her 8 year old brother. She now could make decisions for them without seeking permission through the foster care system. She said she felt relieved because “now my babies are legal and well taken care of.” She denied any significant stress and felt currently supported through the social service system. She said that she would contact the clinic if she had any medical or social concerns.

    Discussion
    Grandparents provide an important and unique role in children’s lives, providing continuity across generations. Grandparents often provide indirect (i.e.suprvising and interacting with the children along with other adults) and direct childcare (being the sole care provider). The childcare arrangements may be informal or formal. In addition to regular child safety issues in any home, grandparent homes need particular attention in a few areas. Medications need to be properly locked out of reach of the children. Walking aids and other mobility equipment should be moved out of the child’s play area if possible. Handrails and bars in bathrooms should be covered with soft material if children will be bathed there. Furniture which may have been used in the past should be checked to see if it meets current safety standards and has nothing broken or loose.

    One study evaluating health of caregiving grandmothers found that rural and urban grandmothers both had similar and good levels of personal physical and mental health. Another study of grandparenthood satisfaction found grandmothers and grandfathers were very satisfied (53%) or satisfied (41%) with their grandparent role. Contact with grandchildren, grandparents own self-esteem and identity were important contributors to their satisfaction as grandparents. For grandmothers, only the role of parent and friend were more important than being a grandparent. For grandfathers, only the roles of parent and spouse were more important than being a grandparent.

    Learning Point
    For children under age 18 in the United States:

    • 50% live with two biological parents
    • 1.3 million live with their grandparents as parents
    • 670,000 live with grandparents in their parent-headed home
    • 2.5 million live with one or more parents in their grandparent-headed home

    About 800,000 children are in the US foster care system during a year (moving into and out of). At any one time about 500,000 are in the system. It is estimated that about 4x that number of children are in informal kinship care which is often grandparental care. Kinship care is good in that children acquire a permanent home more quickly than those in non-kinship care. It also preserves ties to siblings and other family members.

    Children living with a non-parental household are more likely to live with smokers though. Grandparent homes (53.4%) have at least one adult smoker compared to 34.4% of all children in an epidemiological study. When asked about guardianship planning, parents with HIV chose grandparents most often (36%), followed by another relative (34%) and only 17% chose the other biological parent. Young parents and those preferring to speak Spanish were also more likely to choose grandparents as guardians. Grandparents who are the legal guardians themselves also need to consider their own guardianship planning for their grandchildren.

    Questions for Further Discussion
    1. What are the legal procedures for placing children into kinship care in your location?
    2. What are the legal procedures for adoption in your location?
    3. What social services are available locally for grandparents who want to learn more about grandparenting or parenting?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Family Issues and Parenting.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Reitzes DC, Mutran EJ. Grandparenthood: factors influencing frequency of grandparent-grandchild contact and grandparent role satisfaction. J Gerontol B Psychol Sci Soc Sci.2004;59 (1):S9-S16.

    Conway T, Hutson R. Is Kinship Care Good For Kids? Center for Law and Social Policy, March 2007. Available at http://www.clasp.org/publications/is_kinship_care_good.pdf.

    Cowgill BO, Beckett MK, Corona R, Elliott MN, Parra MT, Zhou AJ, Schuster MA. Guardianship planning among HIV-infected parents in the United States: results from a nationally representative sample. Pediatrics. 2007 Feb;119(2):e391-8.

    Cohen GJ. The Prenatal Visit. Pediatrics. 2009;124:1227-1232.

    King K, Martynenko M, Bergman MH, Liu YH, Winickoff JP, Weitzman M. Family composition and children’s exposure to adult smokers in their homes. Pediatrics. 2009 Apr;123(4):e559-64.

    Lumby J. Grandparents and grandchildren: a grand connection. Int J Evid Based Healthc. 2010 Mar;8(1):28-31.

    HealthyChildren.org. Different Types of Families: A Portrait Gallery
    Available from the Internet at http://www.healthychildren.org/English/family-life/family-dynamics/types-of-families/pages/Different-Types-of-Familes-A-Portrait-Gallery.aspx? (rev. 6/11/2010, cited 7/18/2011).

    Bigbee JL, Musil C, Kenski D. The health of caregiving grandmothers: a rural-urban comparison. J Rural Health. 2011 Jun;27(3):289-96.

    Healthy Foster Care America. Facts and Figures. Available from the Internet at http://www.aap.org/fostercare/facts_figures.html (cited 7/18/2011).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Is His Penis Too Small?

    Patient Presentation
    A pediatrician received a consultation about a 3-year-old male admitted for elective pressure equalizing tube surgery, who was noted to have a small penis during pre-operative evaluation. He had been followed by a local physician and according to his parents he was growing and developing properly and was current with his immunizations. He was obese and his parents had received dietary counseling and had made some changes to the family’s diet. The family said that he had no problems urinating or defecating and that he was toilet training. They said he had a normal urinary stream and did not seem to spray the toilet more than another child learning to urinate. The past medical history showed a full-term male infant who was circumcised at birth and was always “a big baby.” He had multiple episodes of otitis media. The family history was positive for coronary artery disease, dyslipidemia and diabetes. There were no congenital abnormalities, endocrinological or neurological problems in the family. The review of systems was negative.

    The pertinent physical exam showed a healthy looking but obese male with normal vital signs. Weight was 22.1 kg (50% for a 6 year old), height was 101 cm (90% for 3 year old). BMI was 21.6 (50% for a 12 year old). Midparental height was 165 cm. HEENT shows scarred tympanic membranes with bilateral fluid. Genitourinary examination did not show a penis but a large suprapublic fat pad. His outstretched penis length was 5.2 cm when measured from the pubic symphysis to the tip of the glans. There was a normal meatal opening and no erythema, but urine in the surrounding fat pad was noted. His scrotum had rugations and both testicles were 2.3 cm in longest length. There were normal cremasteric reflexes, but it was difficult to check for inguinal hernias because of the fat pad. The anus was normally placed. The diagnosis of an inconspicuous but normal penis was made. The family was counseled about the importance of proper hygiene because the penis was buried. The family was also counseled again about the importance of proper nutrition and weight, particularly with the family history. They were offered nutrition counseling at the hospital and declined. They did say that they would return to his regular doctor and would talk with him about possible family lipid testing and obesity management.

    Discussion
    Examination of the genitalia in both genders is an important part of a complete physical examination. For males, a small penis is defined by normative data (see below). A micropenis “… is defined as a stretched penile length of less than 2.5 standard deviations below the mean for age.” Many people will use the terms micropenis and microphallus interchangeably, but others will use the term micropenis to be a short penis but normally formed, and a microphallus to be a short phallus with an associated anomaly such as hypospadias.

    Causes of micropenis are usually genetic (i.e. Kleinfelter, Noonan, Prader-Willi syndromes, etc.) or endocrinological, particularly anywhere along the hypothalamic-pituitary-gonad axis. Testosterone biosynthesis (i.e. 17-beta hydrosysteroid dehydrogenase deficiency) or leutenizing hormone biosynthesis abnormalities can cause micropenis as well as end-organ problems (i.e. 5-alpha reductase deficiency). Hypopituitarism and hypoaldosteronism can cause micropenis, but infants with these abnormalities often also present with other problems including hypoglycemia and electrolyte problems which may lead to shock and even death. Other genital abnormalities may also present with micropenis including hypospadias and cryptorchidism.

    Micropenis is part of the spectrum of ambiguous genitalia. It is also very important to distinguish micropenis from clitormegaly as part of appropriate evaluation and treatment. A child with ambiguous genitalia and their family need to be appropriately evaluated, treated and counseled. This usually requires an institution with an experienced multidisciplinary team including genetics, endocrinology, radiology, urology, surgery and social services.

    It is also important to remember that if the penis size is borderline, meets the criteria for micropenis, has any anatomic abnormalities or there are any concerns about the genitalia not being completely normal, then a circumcision should not be done until a complete evaluation is made.

    Inconspicuous penis is a term that notes a penis that appears small but is not. In the case above the penis was buried in the fat pad. Other reasons aninconspicuous penis include concealed penis, diminutive penis, poor penile suspension, trapped penis, and webbed penis.

    Learning Point

    Penis length should be measured from the base of the pubic symphysis to the tip of the glans. The penis should be stretched to the point of resistance before measuring. A healthy newborn male penis measures 3.5 cm with 2 standard deviations below the mean of < 2.0 cm. A 3 year old male should have a penile length of 5.5 cm with 2 standard deviations below the mean of 3.3 cm. Data for premature infants for gestational ages 24-36 weeks is 2.27 cm + 0.16 X (gestational age in weeks).

    Testicular size can be estimated by volume using Prader models. Most people use long axis length as the standard.

    Tables for penile length and testicular size can be found at Harriet Lane Handbook.

    Questions for Further Discussion
    1. What initial evaluation could be considered for a male with ambiguous genitalia?
    2. What initial evaluation could be considered for a female with ambiguous genitalia?
    3. What are the normal values for testicular size for a full term male infant?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Penis Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Bergeson PS, Hopkin RJ, Bailey RB, McGill LC, Piatt JP. Inconspicuous Penis. Pediatrics. 1993;92(1):794-799.

    Tuladhar R, Davis PG, Batch J. Establishment of a normal range of penile length in preterm infants. J Paediatr Child Health. Oct 1998;34(5):471-3.

    Lee PA, Houk CP, Ahmed F, Hughes IA. Consensus Statement on Management of Intersex Disorders. Pediatrics 2006;118;e488.

    Vogt KS, Kemp S. etc. al. Microphallus. Medscape Reference. Available from the Internet at http://emedicine.medscape.com/article/923178-overview (rev. 7/9/2008, cited 7/5/2011).

    Custer JW, Rau RE. Harriet Lane Handbook. 18th edit. Mosby. Philadelphia, PA. 2009:296.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Coughs?

    Patient Presentation
    A 4-year-old female came to clinic for her health supervision visit. She was doing well but the parents reported that she seemed to have a cough. They said that they noticed it around birth and it had never improved. It occurred mainly around feeding times at day and night and they had not tried anything specifically to help the cough. They denied rhinorrhea, sweating, or color changes. They said that she seemed to have more spitting up than their other child and she seemed uncomfortable after feedings, so they had been placing her in an upright infant seat. A babysitter came to her house for childcare. The past medical history showed a full term infant with no prenatal or natal complications. She was growing normally at her 2 month visit and had received her immunizations. The family history was negative for congenital anomalies or asthma. The review of systems was negative including no recent illnesses.

    The pertinent physical exam showed a smiling female whose weight was continuing to grow at the 50th percentile, and head circumference and length were 75%. HEENT and lung examination were negative. The patient had just fed and the clinician heard the cough and noticed that the infant was spitting up at the time. The infant also did appear to be somewhat uncomfortable with the emesis. The diagnosis of an appropriately growing female infant with a cough that was probably secondary to gastroesophageal reflux was made and the patient was started on lansoprazole. At followup the parents reported that the arching/fussiness behaviors had stopped and the coughing was reduced.

    Discussion
    “A cough is a voluntary or involuntary explosive expiration. After a deep inspiration, the glottis is closed and the expiratory muscles contract, compressing the lung and raising intrapulmonary pressure above the atmospheric pressure. The glottis then opens, and gas is expelled at a rapid rate.”

    Acute coughs are commonly due to upper respiratory tract diseases in children of all ages – often because of post-nasal rhinorrhea. Chronic coughs may be more difficult to determine the cause of and may require more investigation, consultation, and/or empiric trials of medication including radiographic imaging of chest or sinuses, spirotometry, sweat chloride, methacholine challenge, bronchoscopy, gastroscopy, immunodeficiency testing, etc. Children with congenital abnormalities will often have cough but also other “noisy breathing” or “funny cries” if the abnormality affects the overall breathing apparatus. Some of the symptoms and signs which may lead to a diagnosis other than common acute upper respiratory tract disease include abnormal ausculatory findings of the lungs or heart, clubbing, chest pain, dyspnea, failure to thrive, daily wet cough, exposures to infectious disease or environmental irritants such as smoking, other congenital abnormalities, recurrent pneumonia, drug exposures, etc.

    Gastroesophageal reflux is a normal physiological process where stomach contents reflux back into the esophagus which occurs multiple times per day and is cleared by gravity. Gastroesopheageal reflux disease occurs when there is an abnormality of this normal process. Go here for more information about gastroesopheal reflux disease

    Learning Point
    The differential diagnosis of cough includes:

    • Allergic
      • Asthma
      • Allergic rhinitis
    • Congenital
      • Cleft palate
      • Congenital heart disease – including vascular rings, congestive heart failure
      • Laryngeal cleft
      • Laryngeal – cyst, malacia, stenosis
      • Pulmonary malformation – sequestered lobe
      • Tracheoesophageal fistula
      • Tracheobronchomalacia
      • Vocal cord paralysis
      • Webs
    • Genetic
      • Alpha-1-antitrypsin deficiency
      • Cystic fibrosis
      • Dyskinetic cilia
      • Immunodeficiency syndromes
      • Mounier-Kuhn syndrome
    • Infections
      • Bacterial
        • Pertussis
        • Streptococcus pneumoniae
        • Staphylcoccus
        • Tuberculosis
      • Fungal
        • Aspergillosis
        • Coccidiomycosis
      • Viral
        • Adenovirus
        • Human immunodeficiency virus
        • Influenza
        • Measles
        • Parainfluenza
        • Respiratory syncytial virus
        • Rhinovirus
      • Other
        • Chlamydial
        • Mycoplasmosis
      • Disease process
        • Bronchiolitis
        • Bronchitis
        • Croup
        • Otitis Media
        • Pneumonia
        • Post-infectious cough
        • Sinusitis
        • Tonsillitis
        • Upper respiratory infections
    • Miscellaneous
      • Aspiration
      • Bronchiectasis
      • Drug-induced conditions
      • Environmental irritants
      • Foreign body aspiration
      • Gastoesophageal reflux
      • Post-nasal discharge
      • Psychogenic or habit cough
      • Swallowing dysfunction
      • Tourette syndrome
    • Neoplasm/Benign Tumors
      • Hemangiomas
      • Lymphoma
      • Mediastinal tumors
      • Nasal polyp
      • Neurofibroma
      • Papilloma

    Questions for Further Discussion
    1. What are the definitions of acute versus chronic cough?
    2. What are indications for referral to a pulmonologist?
    3. What are indications for computed tomography or bronchoscopy of the lungs?

    Related Cases

      Symptom/Presentation: Cough

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for theses topic: Cough and Gastreosophageal Refux Disease

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:149-155.

    Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:64.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1910.

    Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:196-197.

    Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr. 2010 Mar;156(3):352-8.

    Chang AB, Berkowitz RG. Cough in the pediatric population. Otolaryngol Clin North Am. 2010 Feb;43(1):181-98, xii.

    Ramanuja S, Kelkar PS. The approach to pediatric cough. Ann Allergy Asthma Immunol. 2010 Jul;105(1):3-8.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital