The physicians counseling a 4-year-old child about the death of a loved one should keep in mind that children in this age group:
Correct Answer B:
Children from the ages of 2 to 6 often believe they are somehow responsible for the death of a loved one. The emotional pain may be so intense that the child may react by denying the death, or may somehow feel that the death is reversible. If children wish to attend a funeral, or if their parents want them to, they should be accompanied by an adult who can provide comfort and support. Telling a child the loved one is asleep or that he or she “went away” usually creates false hopes for return, or it may foster a sleep phobia.
A 7-year-old male with moderately severe atopic dermatitis has been treated with a variety of moisturizers and topical corticosteroids preparations over the past year. The results have been less than satisfactory.
Which one of the following topical medications is appropriate at this time?
Correct Answer E:
Tacrolimus is an immunomodulator indicated for the treatment of atopic dermatitis when corticosteroids and other conventional remedies are inadvisable, ineffective, or not tolerated. It is approved for use in patients over 2 years of age.
A 6-month-old Hispanic female has had itching and irritability for 4-5 weeks. There is a family history of atopy and asthma. Physical examination reveals an excoriated dry rash bilaterally over the antecubital and popliteal fossae, as well as some involvement of the face. In addition to maintenance therapy with an emollient, which one of the following topical medications would be appropriate first-line treatment for flare-ups in this patient?
This child has atopic dermatitis (eczema). The infantile stage may present with pruritic, red, scaly, and crusted lesions on the extensor surfaces and cheeks or scalp. The childhood stage is characterized by less exudation and often demonstrates lichenified plaques in a flexural distribution, especially of the antecubital and popliteal fossae, volar aspect of the wrists, ankles, and neck. There often is a family history of atopy or allergies. In addition to the regular use of emollients, the mainstay of maintenance therapy, topical low potency corticosteroids have been shown to be the best first-line treatment for flare-ups of atopic dermatitis.
→ Topical calcineurin inhibitors (choice A) should be second-line treatment for flare-ups, but are not recommended for use in children under 2 years of age.
→ There is no evidence to support the use of topical anesthetics or analgesics (choice B) in the treatment of this disorder.
→ Antihistamines (choice C) provide symptomatic relief of pruritus; may be added to treatment, if needed, but not considered first line treatment in atopic dermatitis.
→ Antibiotics (choice D) should be reserved for the treatment of acutely infected lesions.
The parents of a 20-month-old female bring her to your office because she has lost consciousness twice recently. They describe two episodes where the child was crying vigorously then “turned purple and passed out”. The child is an otherwise healthy product of a term delivery. There is no history of head trauma and no family history of seizures or cardiac problems. The episodes are not associated with fever or other symptoms. Physical examination of the child is normal.
Which one of the following would be most appropriate at this point?
Correct Answer A:
The parents are describing classic breath-holding spells. These are a form of autonomic syncope frequently misdiagnosed as seizures. They occur in early childhood and infancy. They can be of two forms: cyanotic, as described here, and pallid. The cyanotic form usually occurs after vigorous crying, while the pallid form commonly occurs after a sudden fright or minor injury. The history of a prodrome of injury, vigorous crying, or sudden fright is key to distinguishing a breath-holding spell from a seizure. Parents can be reassured that no brain damage occurs and, in the presence of a classic history, no further workup is necessary. An EKG and chest radiograph would be indicated if the history or examination suggested cardiac syncope. Blood testing would be indicated if the history suggested orthostatic hypotension or diabetes. A head CT scan would be indicated in the evaluation of seizures.
A 6-month-old white male is brought to your office because he has “blisters” in his diaper area, neck, axilla, and face. On examination, you find large bullae filled with cloudy yellow fluid. Some of the blisters have ruptured and the bases are covered with a thin crust.
Which one of the following is most appropriate medication in the management of this condition at this point?
Correct Answer D:
Bullous impetigo is a localized skin infection characterized by large bullae; it is caused by phage group II Staphylococcus aureus. Cultures of fluid from an intact blister will reveal the causative agent. The lesions are caused by exfolatin, a local toxin produced by the S. aureus, and develop on intact skin. The bullae initially contain a clear, yellow fluid that subsequently turns cloudy and dark yellow. Bullae rupture easily, within 1-3 days, leaving a rim of scale around an erythematous moist base. After desiccation, the lesion has a brown lacquered or scalded-skin appearance, with a collarette of scale or a tube like rim at the periphery. Removal of the crust reveals a moist, red base. Central healing results in circinate lesions.
Diagnosis of impetigo is usually based solely on history and clinical appearance. Bacterial culture and sensitivity are recommended (1) to identify possible methicillin-resistant Staphylococcus aureus (MRSA), (2) if an outbreak of impetigo has occurred, or (3) if poststreptococcal glomerulonephritis is present.
Infections that are widespread, complicated, or are associated with systemic manifestations are usually treated with antibiotics that have gram-positive bacterial coverage. Systemic therapy is also recommended if multiple incidents of pyoderma occur within daycare, family, or athletic team settings. Beta-lactamase resistant antibiotics (eg, cephalosporins, amoxicillin-clavulanate, cloxacillin, dicloxacillin) are recommended. Cephalexin (choice D) appears to be the drug of choice for oral antimicrobial therapy in children. If MRSA is suspected, alternative antibiotics include clindamycin, trimethoprim-sulfamethoxazole, and vancomycin.
→ Topical antifungal therapy (choice A) is useless against bacterial infections.
→ Topical antibiotic therapy (choice B) is considered the treatment of choice for individuals with uncomplicated localized impetigo. Topical therapy eradicates isolated disease and limits the individual-to-individual spread. Mupirocin ointment (Bactroban) has been used for both the lesions and to clear chronic nasal carriers.
→ Tetracycline (choice C) has been used for localized impetigo. It is not widely prescribed because of the potential risk of skin Photosensitivity reactions and because it is contraindicated in children younger than 8 years. Drugs such as sulfanilamide, nitrofurazone, and silver sulfadiazine, which are widely used for the treatment of burns, are not currently used for the treatment of impetigo.
→ MRSA (choice E) is not suspected at this point and culture results have not been done (clinical vignette).
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