A concerned mother brings in her 18-monthold infant girl. The baby's developmental milestones have been normal. The mother states that there is a "funny glint" in her baby's eyes. She also states that sometimes the infant's eyes look crossed. Which of these supports the diagnosis of a serious life- threatening disease?
Answer(s): C
Leukocoria, a white pupillary reflex, can be caused by several conditions. The most serious, and potentially life threatening, is retinoblastoma. Retinoblastoma is a malignant neoplasm of the retina that may appear as a white mass extending into the vitreous, a mass lesion underlying a retinal detachment or as a diffusely spreading lesion. Retinoblastomas may be unilateral, bilateral, or multifocal. The diagnosis is usually made between 1 and 2 years of age. Other causes of leukocoria may include retinopathy of prematurity, congenital cataracts, toxocarisis (a nematode infection), or Coats disease (a retinal vascular abnormality). The treatment of retinoblastoma may involve surgery, chemotherapy, or other modalities such as cryotherapy and photocoagulation.
A 4-year-old boy is brought to the emergency room by his mother after the child spontaneously admitted to swallowing part of a toy. The child is unable to describe what he ate further, although he appears to be in no distress. His vital signs are normal and his respiratory and abdominal examinations are unremarkable. The child is hungry and is demanding to eat something. ACXR reveals what appears to be a watch battery ("button battery") in the patient's esophagus. What is the best course of action in this situation?
Answer(s): D
The child has ingested a button battery which has lodged in the esophagus. This constitutes a medical emergency and immediate emergency endoscopy is warranted. Button batteries can cause severe esophageal injury and tissue necrosis via electrical current discharge as well as burns from alkali chemicals contained within the battery itself. Severe burns and perforation can occur within hours. Admission for observation is inadequate, and vomiting should not be induced as this could promote aspiration of the battery or gastric contents. Emergency surgery should be reserved for patients in whom endoscopy fails. The patient cannot be discharged with a button battery in the esophagus.
An 18-month-old boy is taken to his family doctor for evaluation of easy bruising and decrease range of motion of the right knee. On examination, he had multiple large ecchymoses, mostly in the lower extremities, and a right knee hemarthrosis. He has not had surgery or family history of a bleeding disorder. Initial blood tests reveal a prolonged activated partial thromboplastin time (aPTT) with a normal PT and platelet count.What further tests should be ordered to make a diagnosis in this boy?
The PTT represents the time for clot formation after adding calcium, phospholipids, and kaolin to citrated blood. It is prolonged by heparin, direct thrombin inhibitors, a deficiency or inhibitor for factors in the intrinsic and common pathway (i.e., factors II, V, VIII, IX, X, XI, XII) as well as lupus anticoagulant, vitamin K deficiency, or severe liver disease. The PT represents the time for clot formation after the addition of thromboplastin (tissue factor) and calcium to citrated blood. It is prolonged with deficiencies of the extrinsic and common pathway factors II, V, VII, X, or fibrinogen; liver disease; vitamin K deficiency and Warfarin use.
Which of the following are currently recommended for all children for every well-child visit?
While all of the screenings listed may be appropriate for children with varying symptoms, only a full physical examination is recommended by the American Academy of Pediatrics for ALL well-child visits.
A23 year old female presents to the emergency department (ED) with "abdominal cramping" nausea, and vaginal bleeding. Ahuman chorionic gonadotropin (hCG) level returns 5150 mIU/mL. A vaginal probe ultrasound is performed and notes no evidence of an intrauterine pregnancy, normal appearing ovaries, a mild amount of fluid in the cul-de-sac, and no evidence of ectopic gestation.The ED physician can exclude which diagnosis from the differential?
Differentiating between an ectopic pregnancy, an early intrauterine pregnancy, or a miscarriage is a common dilemma for the ED physician. Transabdominal ultrasound (TAUS) requires a -hCG level of 6500 mIU/mL before an intrauterine gestation can be confidently visualized. Transvaginal ultrasound (TVUS) is the most accurate means of confirming intrauterine pregnancy and gestational age during the early first trimester. TVUS can help detect signs of intrauterine pregnancy approximately 1 week earlier than TAUS because it has a lower discriminatory zone (-hCG level between 1000 and 1500 mIU/mL). ATAUS that does not detect an intrauterine gestational sac with a -hCG level higher than 6500 mIU/mL or a TVUS examination that does not detect an intrauterine gestational sac when the - hCG level is higher than 1500 mIU/mL suggests an ectopic pregnancy. The literature provides a wide range of sensitivities and specificities for transvaginal ultrasonography in the detection of ectopic pregnancy. Sensitivities range from 69 to 99%, and specificities range from 84 to 99.6%.
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