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Key Points

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  • Inherent differences exist between pediatric and adult patients.

  • Physicians have to treat both the parent and the child.

  • The older the child, the more reliable the clinical impression.

  • Disposition can be affected by unique family situations.

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Introduction

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Infants, children, and adolescents constitute approximately a third of all visits to emergency departments (EDs) in the United States. Of these pediatric visits, more than half are for urgent/nonemergent problems such as otitis media, respiratory and gastrointestinal infections (often viral), asthma, fractures, sprains, soft tissue trauma, and minor head trauma. The challenge of pediatric emergency medicine is to prevent mortality or increased morbidity by catching the few cases that need hospital admission or emergent intervention and ensuring proper discharge of less ill patients.

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Children are considered minors up to their 18th birthday. Although no consent is needed for life-saving interventions, minors require their parent's or guardian's consent for routine medical care and discharge. An exception to this rule is the emancipated minor. “Emancipated minor” status allows a person less than 18 years of age to consent for medical care without parental knowledge, consent, or liability. The exact legal terms of what makes a minor “emancipated” varies slightly from state to state, but generally includes one or more of the following: marriage (including becoming divorced, separated, or widowed), membership in the armed forces, becoming pregnant or having children, living separately from parent(s) or guardian(s), or, finally, demonstrating the ability to manage one's own financial affairs. Of the preceding criteria, discovering a patient is pregnant is the most common situation the authors' have encountered that leads to emancipated minor status.

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Another important legal issue for clinicians working with children is our role as mandated reporters. We have a duty to protect vulnerable young patients. If there is reasonable cause to suspect that a child has been abused, neglected, or placed in imminent risk of serious harm, we are obligated to involve government agents such as child protective services, police, etc.

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There are many aspects of clinical pediatric emergency medicine that differ from adult emergency medicine practice. Not only must you vary your approach to each patient based on their anatomic, physiologic, and developmental status, you also have to establish an effective relationship with the patient and his or her caregiver. In other words, physicians have to treat both the parent and the child. We review some of these differences later in this chapter.

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Clinical Presentation

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History

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Obtain as much information as possible from the child. Questions should be direct and stated in terms the child can understand. Further details and clarifications should be sought from the parents, guardians, or caregivers. The younger the child, the greater reliance on history obtained from the parents, and the more the history may be influenced by the parent(s)' perception of symptoms. When taking ...

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