Case history
Case history #1
A mother brings her 5-month-old son to the office with the chief complaint of diarrhea and diaper rash. On exam, he is fussy and appears ill. His vital signs are notable for a heart rate of 200 bpm (normal range for age: 100-160 bpm), a respiratory rate of 48 breaths/minute (upper normal limit 40 breaths/minute), and a BP of 105/50 mmHg (95th percentile for systolic BP is 103 mmHg for a child of approximately 5 months old). His abdomen is soft with active bowel sounds. He has a diffuse red, inflamed rash with superficial excoriation. His mouth looks tacky and he refuses a bottle or pacifier. His mother reports that he has had frequent nonbloody watery stools for 2 days but has had only one today. His diaper is dry.
Case history #2
A mother brings her 4-month-old daughter to the office because of vomiting. She states that the baby has been fine until yesterday, when she seemed fussier than usual. Today she will not take a bottle. She has had no fever, diarrhea, or known contact with any infectious disease. On exam, the baby is extremely lethargic, pale, and tachycardic (180 bpm), with a BP of 105/45 mmHg. Capillary refill is brisk, there is normal skin turgor, and mucous membranes appear moist. Skin exam is normal except for a circumferential area of faint bruising of the right upper arm. Abdominal exam is notable for apparent tenderness without guarding. The liver edge is 2.5 cm below the right costal margin.
Other presentations
Although gastroenteritis is the most frequent cause of volume depletion in children, other etiologies are encountered in pediatric practice. Two broad categories of volume depletion can be considered. The first includes conditions resulting from an imbalance between fluid intake and output (e.g., diabetic ketoacidosis, diabetes insipidus, excessive sweating, hemorrhage, and insufficient intake of fluid to maintain homeostasis). The second category is far less common in pediatric patients but may be life-threatening. It consists of conditions resulting from a maldistribution of total body fluid (e.g., anaphylaxis, ascites, occult bleeding, and sepsis).
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