A 5-year-old child is diagnosed with juvenile rheumatoid arthritis.
Which of the following is the least likely side effect of therapy with a non-steroidal anti-inflammatory drug?
Correct Answer B:
NSAIDs are associated with a number of side effects. The most common side effects are nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. NSAIDs may also cause tinnitus and fluid retention, leading to edema. The most serious side effects are kidney failure, liver failure, ulcers and prolonged bleeding after an injury or surgery. Some individuals are allergic to NSAIDs and may develop shortness of breath when an NSAID is administered. People with asthma are at a higher risk for experiencing serious allergic reaction to NSAIDs.
A 5-year-old boy was rushed to the hospital because his mother strongly believes that he ingested an unknown large number of Tylenol (acetaminophen) tablets an hour ago. The child looked well but nauseated.
The best action to take at this time is:
Correct Answer E:
In addition to focusing on the ABCs, oral administration of activated charcoal is a useful course of action for a subject with acetaminophen poisoning during the first two hours. More important than GI decontamination is the early administration of Nacetylcysteine (NAC). NAC is nearly 100% hepato-protective when it is given within 8 hours after an acute acetaminophen ingestion. Oral administration is the preferred route for NAC therapy unless contraindications exist (e.g aspiration, persistent vomiting).
When faced with a patient with drug poisoning, the course of action is dictated by the pharmacokinetics and pharmacodynamics of the drug ingested.
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.
Your patient desires more information about breast enlargement in males.
Which of the following information should not be given?
Correct Answer A:
Gynecomastia is an abnormal enlargement of one or both breasts in men. Milk production may or may not be present. Gynecomastia is fairly common. It is a physiologic phenomenon that occurs during puberty, when at least half of males experience enlargement of one or both breasts. Pubertal hypertrophy is characterized by a tender discoid enlargement of the breast tissue beneath the areola and usually subsides spontaneously within a year. It may be unilateral or bilateral and is diagnosed on exam as a palpable rubbery or firm mass of tissue at least 0.5 cm in diameter (usually underlying the nipple). Physiologic gynecomastia, which resolves spontaneously in most cases, has a trimodal distribution, occurring in neonatal, pubertal, and older males (choice B).
There are many drugs that have been associated with gynecomastia. Drugs with the best evidence for an association with gynecomastia include spironolactone, cimetidine, ketoconazole, recombinant human growth hormone, estrogens, human chorionic gonadotropin (hCG), anti-androgens, gonadotropin-releasing hormone (GnRH) agonists, and 5-alpha-reductase inhibitors. (choice C).
The causes of gynecomastia are multiple. A search for a common mechanism has not been successful. A number of researchers believe that in many cases (but not all), an altered androgen/estrogen ratio (choice D) causes changes in cellular elements in breast tissue. This could be due to: decrease in production of androgen, increase in estrogen formation and a decrease in sensitivity of breast tissue to androgens.
The diagnosis of gynecomastia is made on physical examination. Imaging is not routinely recommended unless there is concern for possible breast cancer: unilateral, nontender, and/ or fixed masses found eccentric to the nipple-areolar complex (choice E). Mammography is the most sensitive imaging modality for detecting malignancy, while ultrasonography is the most specific.
This patient does not show any warning signs and biopsy is not indicated (choice A).
During a health maintenance examination, a 14-year-old black male is noted to have asymmetric breast enlargement with mild tenderness. The remainder of the physical examination is normal.
The most appropriate management in this case is to:
Some gynecomastia occurs in 30%-50% of pubertal males. It typically appears between 12 and 15 years of age, at Tanner stages 2 and 3. Physiologic gynecomastia is usually mild and may be either unilateral or bilateral. Breast tenderness is common and also mild. The enlargement typically regresses within a few months to 2 years.
→ Serum hormone levels are the same as in boys without gynecomastia, although the ratio of testosterone to estrogen is lower than in males at similar stages without the condition.
→ There is no indication for chromosomal investigation or radiography.
→ A biopsy should be considered only if the condition persists beyond mid-puberty.
A 17-year-old university student visits her family physician’s office complaining of fatigue and “strong smelling” urine. She is a member of the university basketball team and has noted a dip in her performance since the onset of these symptoms. Urine analysis shows specific gravity 1030, nitrites negative, + protein. A 24 hour urine collection shows a normal creatinine clearance with 0.41 g of protein for this time period.
Which of the following investigation(s) does this patient require?
Exercise proteinuria is transient in nature and is not associated with a pathological condition. The magnitude of proteinuria varies from near normal to heavy, with the greatest levels (up to 100 times that of rest) observed after high-intensity exercise.
An increased quantity of protein in the urine may be due to an increased filtration of plasma protein through the renal glomerulus and into the renal tubule. This is termed "glomerular proteinuria", with albumin comprising the greatest proportion of excreted proteins (albuminuria). Glomerular proteinuria regularly occurs in response to dynamic exercise, regardless of the exercise intensity.
In an athlete with proteinuria, urinalysis should he repeated after a period of 48 to 72 hours free from exercise.
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