A 10-year-old boy presents with red discoloration of the urine since the morning. He is healthy and otherwise asymptomatic. He denies dysuria, frequency, urgency, flank, or abdominal pain. His BP is normal. His examination is within normal limits including abdomen and genitourinary system. There is no rash or edema. His urine is pink in color; urinalysis is negative for hemoglobin or protein. No white cells, red cells, or bacteria are noted. Which of the following is the most appropriate next step?
Answer(s): A
There are many drugs and foods that cause red urine. These include azo dyes, beets, blackberries, ibuprofen, methyldopa, red food color, rifampin, phenolphthalein, pyridium, sulfasalazine, and many others.Dark brown or black urine can be associated with alanine, cascara, resocinol, and thymol. If the diet or drug history as well as dipstick are negative, porphyrinuria should be considered. A positive reagent strip (dipstick) indicates hemoglobin or myoglobin. Negative dipstick and normal urinalysis makes renal pathology unlikely. Because the urinalysis is negative, and the patient is asymptomatic, urine culture is not indicated at this time. Test for antistreptococcal antibodies should be done if poststreptococcal glomerulonephritis is suspected; it is characterized by proteinuria, hematuria, edema, and hypertension.
A 12-year-old girl has had a sore throat over 2 days. She now has a fever of 39.5°C and has difficulty opening her mouth, swallowing, or speaking. Her throat can be visualized with difficulty, the right tonsil is significantly more enlarged than the left, and the uvula is displaced to the left side. Which of the following is the most likely diagnosis?
Answer(s): C
This is a classic presentation for a peritonsillar abscess. Development of a peritonsillar abscess is usually preceded by acute pharyngotonsillitis, followed by development of severe throat pain and trismus. It is usually caused by group A hemolytic Streptococci or oral anaerobes in preadolescent or adolescent patients. Speech is often with a "hot potato" voice. The affected tonsil is enlarged causing the uvula to be pushed to the other side. Antibiotics (penicillin) and incision and drainage are usually required.Retropharyngeal abscess is usually a complication of bacterial pharyngitis in younger children under age 34 years. It is caused by infection and further suppuration of nodes in the retropharyngeal area. Symptoms include high fever, difficulty swallowing, feeding refusal, hyperextension of the head, and drooling. There is bulging of the posterior pharyngeal wall; diagnosis can be confirmed by widening of the retropharyngeal space on x-ray. With lateral pharyngeal abscess there is bulging of the lateral pharyngeal wall. Acute uvulitis is caused by group Ahemolytic Streptococci and H. influenzae type B, often in association with tonsillitis and uvulitis.
An 18-month-old boy presents with a history of fever to 39.0°C for 5 days. He has also been irritable and has not been drinking well. Associated symptoms include red eyes, a rash, and some trouble walking. On physical examination, he has a temperature of 39.5°C. He has bilateral bulbar conjunctivitis, a strawberry tongue, an inflamed oral pharynx, edema of the hands and feet, a morbilliform rash, and cervical lymphadenopathy. He is very irritable. His CBC shows a WBC of 15,000/mm3 with 60% neutrophils, 35% lymphocytes, and 5% monocytes. His hemoglobin is 12.0 g/dL and platelet count is 500,000/ mm3.Which of the following is the most likely diagnosis?
Answer(s): B
Kawasaki disease is an acute febrile illness of unknown etiology that typically affects young children, usually those under 5 years of age. There are six clinical criteria used for diagnosing this disease. The presence of 5 days or more of fever, in addition to four of the five additional criteria, establishes the diagnosis. The five additional criteria are bilateral bulbar nonexudative conjunctivitis, rash, hand and foot changes (edema followed by desquamation), oral changes such as strawberry tongue and erythema, and cervical lymphadenopathy. Erythema infectiosum presents with a prodrome of malaise and myalgia and then with local erythema of the cheeks (slapped cheeks). Rubella and rubeola are unusual because of the MMR vaccination. Rubeola presents with the three "Cs"--cough, coryza, and conjunctivitis-- followed by the oral inflammation and the pathognomonic Koplik spots, rash, and fever. Rubella is typically a mild disease characterized by low-grade fever and a maculopapular rash. Rheumatic fever is also unusual. It tends to present in children over 3 years of age after an infection with group A Streptococci, with transient migratory arthritis, carditis, chorea, rash, and nodules.Diagnosis is made according to the Jones criteria.
An athletic 12-year-old boy complains of left knee pain when he runs and plays sports. The pain resolves when he rests. He has otherwise been well. His physical examination is normal, except for swelling and increased prominence over the left tibial tubercle. Aradiograph of the left knee is normal.Which of the following is the most likely diagnosis?
Osgood-Schlatter results from microfractures and inflammation of the tibial tubercle where the patellar tendon inserts. It is most commonly seen in young adolescents who are involved in athletics. Legg- Calvé- Perthes disease is idiopathic avascular necrosis of the capital femoral epiphysis and presents between the ages of 2 and 12 with a painless limp. Patellar subluxation is usually due to a congenital deficiency within the patellofemoral joint. On examination, these patients have tenderness over the inferior surface of the patella and terminal subluxation of the patella when the knee is fully extended. Popliteal cysts are usually asymptomatic and present with a fluidfilled mass in the popliteal fossa. The symptoms of slipped capital femoral epiphysis are variable but typically involve hip pain and limp. On examination, patients have limitation of motion in the hip. It is most common in obese adolescents
Apreviously healthy male postal worker complains of fever, headache, myalgia, and cough for the past 3 days. He reports that several of his coworkers have also been ill with similar complaints. His leukocyte count is normal with a relative lymphopenia. Achest x-ray shows only enlarged hilar shadows. Which of the following is the most likely cause of this infection?
Onset of influenza usually is abrupt, with fever, chills, fatigue, headache, myalgias, malaise, anorexia, scratchy throat, and nonproductive cough. Fever appears early and may reach 40°C (104°F). Myalgias affecting the back and legs, and retrobulbar headache are worse with high fever. There is a normal leukocyte count with relative lymphopenia. Chest x-ray may show enlarged hilar shadows. Fever lasts a few days. Upper and then lower respiratory symptoms become more prominent, and cough may persist for weeks. Respiratory anthrax is exceedingly rare. Initial symptoms may resemble influenza, but rhinorrhea is rare. X-rays generally show patchy lung infiltrate and mediastinal widening (due to enlarged hemorrhagic lymph nodes). Early treatment with antibiotics such as ciprofloxacin sometimes prevents death.
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