A 14-year-old boy complains of breast enlargement on the left side. He denies pain, discharge, or any drug use. He is on no medications and is otherwise healthy. On physical examination, his sexual maturity rating (Tanner) is stage II for both genitalia and pubic hair growth. Initial management should include which of the following?
Answer(s): D
Gynecomastia is the enlargement of male breast tissue and occurs in approximately onethird of adolescent males during early- to midpuberty. It usually resolves spontaneously and requires no further evaluation beyond a careful history and physical examination. Features include: breast tissue <4 cm in diameter and resembling female breast budding, and pubertal development between Tanner stage II and IV. Pubertal development signs precede gynecomastia by at least 6 months. It may be more noticeable in obese boys.A drug and medication history should be obtained; these include estrogens, androgens, human chorionic gonadotropin (hCG), cardiovascular drugs (reserpine, methyldopa, digitalis), cytotoxic agents (busulfan, vincristine), antituberculosis drugs (INH), psychoactive drugs (tricyclic antidepressants, diazepam), ketoconazole, spironolactone, cimetidine, and phenytoin. Illegal drugs include marijuana, heroin, methadone, amphetamines, as well as alcohol. If there is evidence of precocious puberty, hypogonadism or macrogynecomastia (breast tissue >5 cm diameter), laboratory testing should be done including dehydroepiandrosterone sulfate (DHAS), FSH, and LH, hCG, estradiol, and testosterone. Thyroid- stimulating hormone (TSH) may be obtained to rule out hyperthyroidism. Boys with Klinefelter syndrome have hypogonadism (testes <3 cm in diameter), delayed pubertal development, and gynecomastia.Laboratory tests reveal increased FSH and LH, and decreased testosterone; the diagnosis is confirmed by chromosome analysis. If DHAS, hCG, or estradiol levels are increased, an MRI of the head to exclude a CNS tumor and ultrasound of abdomen and testes to rule out an adrenal, liver, or testicular tumor should be considered.
Amother brings in her 3-year-old girl because she felt a smooth mass on the left side of her belly when she was giving her a bath. Which of the following is the most likely diagnosis?
Answer(s): A
Wilms tumor is a malignant embryonal neoplasm of the kidney. It is the second most common solid tumor of childhood. Girls are affected more frequently than boys (2:1). The incidence of Wilms tumor peaks at 13 years of age. The classic presentation is a painless abdominal mass that is usually hard, smooth, and unilateral. Hematuria occurs in 1225% of children with Wilms tumor, and hypertension has been reported in up to 60% of patients. Aniridia or hemihypertrophy may be observed in patients with Wilms tumor.
An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.You decide to obtain a urine specimen for analysis and culture. Which of the following is the best method?
Answer(s): B
Urine for urinalysis and culture must be properly obtained. Catheterization is the most reliable method of the choices offered. Suprapubic tap is considered the "gold-standard" but is not always technically feasible, especially in an outpatient office setting. Amidstream, clean catch specimen would be acceptable in an older, toilet-trained child. "Bagged" specimens are not recommended because of possible skin or fecal contamination of the specimen. Similarly, obtaining a sample from a diaper or potty would be unacceptable.Urinalysis includes dipstick method and microscopic examination. Leukocyte esterase (an enzyme in WBC) and nitrites suggest probable infection. Microscopic analysis of unspun urine for WBC (>10/ highpower field) or bacteria is also predictive of infection. RBCs are often present in a UTI. The patient is vomiting and dehydrated; this may indicate possible pyelonephritis. The most appropriate course would be IV hydration and empiric treatment with antibiotics (ceftriaxone) while awaiting cultures. Children with pyelonephritis are at increased risk of renal scarring, especially younger children, and should be treated early. E. coli is the most common organism cultured; others include Proteus, Klebsiella, S saprophyticus, and Enterococcus. The occurrence of a UTI in a girl under age 35 years and in a boy of any age may be a marker for an underlying congenital anatomic abnormality, in particular, vesicourethral reflux. Radiologic investigation with renal ultrasound and VCUG is recommended
An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.Her urine culture is positive at 24 hours. Which of the following is the most likely organism?
An 11-month-old girl presents to your office with a fever of 39°C she has had for 2 days. She has also vomited frequently and had decreased fluid intake. She looked tired and ill but on examination, had no apparent source of infection. She appeared to be 510% dehydrated.After the infection has been treated, which one of the following tests should be considered ?
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