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Appendix H: Differential Diagnosis Table

Clinical Findings Differential Diagnosis Differential Tests
CUTANEOUS LESIONS    
bulletBruising Trauma Rule out other disease
  Hemophilia Prothrombin time, partial prothromboplastin time
  Von Willebrand's disease Von Willebrand's panel
  Henoch Schonlein purpura Typical distribution of lesions
  Purpura fulminans Rule out sepsis
  Ehlers-Danlos syndrome Hyperextensibility
bulletLocal erythema or bullae Burn Clinical history and characteristics
  Staphylococcal impetigo Culture, Gram stain
  Bacterial cellulitis Culture, Gram stain
  Pyoderma gangrenosum Culture, Gram stain
  Photosensitivity and phototoxicity reactions History of sensitizing agent, oral or topical reactions
  Frostbite Clinical history and characteristics
  Herpes, zoster or simplex Scraping, culture
  Epidermolysis bullosa Skin biopsy
  Contact dermatitis, allergic or irritant Clinical characteristics
 
OCULAR FINDINGS    
bulletRetinal hemorrhage Shaking or other trauma  
  Bleeding disorder Coagulation studies
  Neoplasm  
  Resuscitation History
bullet Conjunctival hemorrhage Trauma Culture, Gram stain
  Bacterial or viral conjunctivitis History
  Severe coughing  
bullet Orbital swelling Trauma  
  Orbital or periorbital cellulitis Complete blood count, culture, sinus radiographs
  Metatastic disease Radiograph, CT scan, CNS examination
  Epidural hematoma Radiograph, CT scan, CNS examination
 
HEMATURIA Trauma Rule out other disease
  Urinary tract infection Culture
  Acute or chronic forms of glomerular injury (e.g., glomerulonephritis) Renal function tests, biopsy
  Hereditary or familial renal disorders (e.g., familial benign recurrent hematuria) History
  Other (e.g., vasculitis, thrombosis, neoplasm, anomalies, stones, bacteremia, exercise) History, cultures, radiologic studies
 
ACUTE ABDOMEN Trauma Rule out other disease
  Intrinsic gastrointestinal disease (e.g., peritonitis, obstruction, inflammatory bowel disease, Meckel's diverticulum) Radiographs, stool tests, and others
  Intrinsic urinary tract disease (infection, stone) Culture, ultrasound, intravenous pyelogram
  Genital problems (e.g., torsion of spermatic cord, ovarian cyst) History, physical examination, ultrasound, radiograph, laparoscopy
  Vascular accident, as in sickle cell crisis Angiography, sickle cell studies
  Other (e.g., mesenteric adenitis, strangulated hernia, anaphylactoid purpura, pulmonary disease, pancreatitis, lead poisoning, diabetes) As appropriate
 
OSSEOUS LESIONS    
bullet Fractures (multiple or in various stages of healing) Trauma  
  Osteogenesis imperfecta Radiographic and blue sclerae
  Rickets Nutritional history
  Birth trauma Birth history
  Hypophosphatasia Decreased alkaline phosphatase
  Leukemia Complete blood count, bone marrow
  Neuroblastoma Bone marrow, biopsy
  Status after osteomyelitis or septic arthritis History
  Neurogenic sensory deficit Physical examination
 
METAPHYSEAL LESIONS, EPIPHYSEAL LESIONS, OR BOTH Trauma  
  Scurvy Nutritional history
  Menkes syndrome Decreased copper, decreased ceruloplasmin
  Syphilis Serology
  "Little League" elbow History
  Birth trauma History
 
SUBPERIOSTEAL OSSIFICATION Trauma  
  Osteogenic malignancy Radiograph and biopsy
  Syphilis Serology tests
  Infantile cortical hyperostosis No metaphyseal irregularity
  Osteoid osteoma Response to aspirin
  Scurvy Nutritional history
 
SUDDEN INFANT DEATH SYNDROME Unexplained death Autopsy
  Trauma Autopsy
  Asphyxia (aspiration, nasal obstruction, laryngospasm, sleep apnia) "Near-miss" history
  Infection (e.g., botulism) Cultures, bacterial and viral
  Immunodeficiency Immunoglobulins
  Cardiac arrhythmia Autopsy
  Hypoadrenalism Electrolytes, ACTH stimulation test
  Metabolic abnormality Ca++, Mg++, other
  Hypersensitivity to cow's milk protein  

Adapted from Newberger EH. Child Physical Abuse. Primary Care 1993; 20(2):317-27.

Source: Vandeven A and Knight JR. Physical Abuse: The Father’s Handprint, Handout #1: Differential Diagnosis of Child Abuse. In: Knight JR, Frazer C, Emans SJ, eds. Bright Futures Case Studies for Primary Care Clinicians: Child Development and Behavior. Boston, MA: Bright Futures Center for Education in Child Growth and Development, Behavior, and Adolescent Health; 2001.


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Appendices  Appendix A: Post-Assault Testing and Treatment  Appendix B: A Sample Continuum of Medical History Questions and Confidence in the Responses  Appendix C: Body Diagrams  Appendix D: Burn Assessment - Rule of Nines  Appendix F: Common Types of Diaphyseal Fractures Seen in Childhood  Appendix G: Findings That May Be Confused with Abuse  Appendix H: Differential Diagnosis Table  Appendix I: List of Community Services  Appendix J: Supplemental Resources  Appendix K: Emergency Contraceptive Pills 

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