You perform a health maintenance examination on a 2-year-old white male. He is asymptomatic and is meeting all developmental milestones. The only significant finding is a grade 3/6 diastolic murmur heard at the right upper sternal border.
Which one of the following would be the most appropriate at this time?
Correct Answer B:
Children who have a murmur that is diastolic or is greater than 3/6 should be referred for cardiovascular evaluation, perhaps after an echocardiogram is obtained. Other reasons for referral include cardiac symptoms, abnormal splitting of S2, a murmur that increases on standing, a holo-sytolic murmur, or ejection clicks. Digoxin is not indicated at this point in this asymptomatic patient.
You are working in the emergency department of a large urban hospital when a 4-month-old boy is brought in with a soft swelling on the right side of the head. The boy’s mother says that the baby has been eating and acting normally. She is unaware of any head trauma. The baby appears happy and playful, and there are no old bruises or scars. A CT scan of the head reveals no intracranial hemorrhage, but a linear skull fracture of the right parietal bone is seen by the radiologist.
What would you do next?
Correct Answer D:
A workup for suspected non accidental trauma should include a careful history to determine if the explanation is consistent with the nature and degree of the injury and consistent with the developmental age of the child. Skeletal radiographs to look for old and new fractures are important. Retinal hemorrhages may be associated with shaken baby syndrome. Clotting disorders should be ruled out in children with bruising.
A. A confrontational approach may cause the mother to flee the emergency department with the baby. It is important to remain calm and carry out the evaluation in a professional manner.
B. Unless associated with intracranial hemorrhage, linear skull fractures are generally not associated with severe brain damage.
C. This child does not have a medical condition that warrants admission to an intensive care unit. In fact, if a safe home environment can be assured, hospital admission may not be necessary.
E. In cases of suspected child abuse, the baby should not be sent home until the Child Protective Services agency has completed an evaluation and determined the home setting to be safe.
A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The remainder of the examination is within normal limits.
Which one of the following would be the most appropriate management for this patient?
Correct Answer A:
Any child younger than 29 days old with a fever, and also any child, regardless of age, who appears toxic, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated.
Observation only, with close follow-up, is recommended for nontoxic infants 3-36 months of age with a temperature <39.0°C (102.2°F). Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and urinalysis, can be sent home with precautions and with follow-up in 24 hours. Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics.
A 3-year-old male is carried into the office by his mother. Yesterday evening he began complaining of pain around his right hip. Today he has a temperature of 37.6°C (99.7°F), cries when bearing weight on his right leg, and will not allow the leg to be moved in any direction. A radiograph of the hip is normal.
Which one of the following would be most appropriate at this time?
This presentation is typical of either transient synovitis or septic arthritis of the hip. Because the conditions have very different treatment regimens and outcomes, it is important to differentiate the two. It is recommended that after plain films, the first studies to be performed should be a CBC and an erythrocyte sedimentation rate (ESR). Studies have shown that septic arthritis should be considered highly likely in a child who has a fever over 38.7 degrees C (101.7 degrees F), refuses to bear weight on the leg, has a WBC count 3 > 12^9/L, and has an ESR > 40 mm/hr. If several or all of these conditions exist, aspiration of the hip guided by ultrasonography or fluoroscopy should be performed by an experienced practitioner. MRI may be helpful in cases that are unclear based on standard data, or if other etiologies need to be excluded.
A 14-year-old male presents to your office complaining of recent growth of his breasts. He has a history of cardiac disease and is currently taking digoxin and hydrochlorothiazide. On examination your patient is slim, his blood pressure is 160/96 mmHg, and he has bilateral non-tender gynecomastia. The remainder of his physical examination is within age normal limits.
The patient asks you why his breasts are growing and you site which of the following reasons as the most likely cause?
Certain medications can promote breast growth. They interact with the natural levels of testosterone and estrogen, and upset the balance in some manner. Gynecomastia is a common consequence of estrogen treatment in patients with prostate cancer. Drugs that may cause gynecomastia include: Hormones (androgens, anabolic steroids, estrogen agonists), antiandrogens or androgen-synthesis inhibitors, antibiotics (isoniazid, ketoconazole, metronidazole), anti-ulcer medications such as cimetidine, cancer chemotherapeutics, especially alkylating agents and cardiovascular drugs, such as captopril and digoxin (digitalis).
Click to expand