Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given.The parents are concerned about fetal alcohol syndrome (FAS). Which physical feature is most consistent with FAS?
Answer(s): A
Repeating all serologies is important. The prior negative testing should be included in the medical record, but should not dissuade one from confirming the result. The collection of stool for ova and parasites (O + P) is an important evaluation but should not be the only testing performed. ACBC is not an adequate screen for infections.The diagnosis of FAS includes findings of characteristic facies, growth retardation, and CNS impairment. The characteristic facies of FAS includes flat philtrum, thin upper vermilion border, short palpebral fissures, micrognathia, microphthalmos, and microcephaly.BCG is a common vaccine administered in countries outside of the United States. The presence of a positive reaction to a PPD in a child who has had a prior BCG is still concerning. The presence of a 15- mm reaction is considered positive and warrants a CXR and initiation of anti TB treatment. The negative CXR would indicate TB exposure, and INH alone is recommended. Sputum collection is usually unwarranted in asymptomatic children.
Parents bring you a 9-month-old boy they recently have adopted from western Russia. They have sparse medical records of the child's past. They do know that the boy was the result of a sexual assault on the mother and was given up at birth. The child has been in a "baby home" for 5 months. The records which accompanied the boy indicate that there had been some testing done. These tests include HIV, hepatitis B and C serologies, and a rapid plasma reagin (RPR), all of which are negative at 8 months of age. There is what appears to be a Russian immunization record as well. It seems to indicate that the child has had three diphtheria, tetanus, pertussis (DTP), three oral polio, and three hepatitis B vaccinations. There is also an indication that BCG (Bacille Calmette-Guérin) was given.You place a purified protein derivative (PPD) and the parents come back in 48 hours to have it read. The response is 15 mm of induration. The boy does not have any respiratory symptoms at this time.What is the most appropriate response to this information?
Answer(s): D
A 9-year-old boy comes to the clinic for evaluation of a rash. The boy says that he began developing some blisters on his cheek the night prior. He says that over the past few days he has spent time outside with his friends "down by the creek." The rash appears to be a linear crop of vesicles beginning in front of his left ear and extending to the corner of his mouth. There is no erythema, and he describes them as quite pruritic. He has not had any fever, vomiting, or changes in his hearing.What does this rash most likely represent?
Answer(s): C
This represents an allergic contact dermatitis. The allergen is the oil on the leaf of certain plants (poison ivy). The reaction is a delayedtype hypersensitivity reaction (type 4) and may take up to 7296 hours after exposure to fully manifest. Limited allergic contact dermatitis will usually warrant limited therapy. Oral antihistamines, taken on an as-needed basis, can provide effective symptomatic relief. Topical antihistamines are usually not effective and, if added to oral antihistamines, can result in toxic effects. Steroids should be used sparingly on the face, and high-potency steroid should not be used at all on the face. Secondary infection is unlikely if good skin hygiene is used.
A 9-year-old boy comes to the clinic for evaluation of a rash. The boy says that he began developing some blisters on his cheek the night prior. He says that over the past few days he has spent time outside with his friends "down by the creek." The rash appears to be a linear crop of vesicles beginning in front of his left ear and extending to the corner of his mouth. There is no erythema, and he describes them as quite pruritic. He has not had any fever, vomiting, or changes in his hearingAlong with good skin hygiene, which of the following is the best treatment plan for this child?
Answer(s): B
A 16-year-old woman comes to see you for a yearly physical examination. Her only concern is that her periods are very irregular, and she desires oral contraceptives to regulate them. She relates that menarche was at 12 years, of age and that her periods have always been irregular. On examination, she is a markedly obese woman with a body mass index of 35 and with normal linear growth. She has some coarse facial hair down both of her checks as well as cystic acne along her hairline. On the nape of her neck she is noted to have acanthosis nigricans. She has tanner 4 breast development as well as tanner 4 pubic hair.Her urinalysis in the office is normal.What is the most likely cause of her irregular periods?
This clinical vignette describes an adolescent female with PCOS. PCOS is commonly seen in obese adolescent females with anovulatory menstrual cycles, hirsutism, and generalized virilization (acne). Commonly, PCOS patients will have glucose insensitivity and manifest features of type II diabetes mellitus. The diagnosis of PCOS may be difficult to ascertain. A pelvic ultrasound demonstrating "polycystic ovaries" (the string of pearls sign) may be quite helpful. Girls with PCOS will typically have elevated triglycerides, low HDL cholesterol, and a suppressed prolactin. As indicated above, PCOS girls also often have glucose insensitivity and an abnormal glucose tolerance test. The most effective therapy in PCOS involves lifestyle alterations (weight loss and exercise) and hormonal regulation of ovulation. The hypoglycemic agent metformin is now being used to assist in the management of PCOS. Occasionally, subcutaneous insulin may be effective in controlling hyperglycemia, but this will not prevent diabetes mellitus.
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