Question of the Week # 476

476. You are evaluating a 12 month old male patient for rhinorrhea and poor appetite. He is friendly and alert. His temperature today is 103.6 degrees Fahrenheit, and his examination is significant for clear nasal discharge and multiple small vesicles on the anterior tonsillar pillars and posterior palate. His examination is otherwise normal. He is accompanied by his mother who seems to be very concerned. The patient has been feeding well and all his developmental milestones have been timely so far. A complete blood count is normal.  Which of the following is his most likely diagnosis?

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

A. Hand, foot, and mouth disease

B. Apthous stomatitis

C. Herpangina

D. Stevens-Johnson syndrome

E. Kawasaki disease

Question of the Week # 472

A 9-year-old boy is brought to the hospital with a wound to his left hand. He was in a fight with peer who bit him. His past medical history is unremarkable and he takes no medications. He has no known allergies. On examination, the child is crying. There is a 2-cm wound over the dorsum of his palm. What is the most appropriate course of action?
A. Clean the wound and prescribe amoxicillin-clavulanate.
B. Clean the wound and prescribe doxycycline.
C. Clean the wound and prescribe ciprofloxacin.
D. Clean the wound, close it with interrupted sutures and prescribe ciprofloxacin.
E. Clean the wound, close it with interrupted sutures and prescribe amoxicillin-clavulanate.

Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

Question of the Week # 468

468) An 18-month-old girl is brought to the hospital by her parents because of a high fever and generalized “body shaking” 2 hours ago. The parents say that she was “pretty fussy” all day and her temperature at that time was 37.3 °C (99.2 °F). Over the past few hours, she began to “burn up,” with her temperature spiking to 39.7 °C (103.4 °F). They put her into her crib to go to sleep, and they heard “banging” coming from the baby monitor in their bedroom. When they arrived in her room 10 seconds later, her entire body was “shaking”. It lasted about 2 minutes, and did not recur. She was lethargic and drowsy for 5 minutes after the “shaking”. Nobody in the family has ever had a seizure before. Her temperature is 39.3 °C (102.8 F). Neurologic examination is unremarkable. A chest x-ray shows a left lower lobe consolidation.

A lumbar puncture shows:

Color clear

Glucose 55 mg/ml

Protein 22 mg/ml

Lymphocytes 4/ml

The parents are concerned about the severity of their daughter’s condition and what they can expect in the future. The most appropriate response is which of the following?

A. “Luckily, you got to the hospital in time to avoid complications such as hydrocephalus, hearing loss, speech or developmental delays, and mental retardation.”
B. “Since you do not have a family history of febrile seizures, chances are that she will go on to have idiopathic epilepsy.”
C. “This episode is due to her pulmonary infection, and it will never recur.”
D. “Your daughter will most likely have a complete recovery and there is only a very small chance that she will develop epilepsy.”
E. “Your daughter’s condition is very serious and a full evaluation for epilepsy is indicated at this time.”

Question of the Week # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 348

348)  A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks.  He does not have any significant past medical problems  There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at  7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?

A) Admit and start Albumin infusion

B) Corticosteroid Trial

C) Renal Biopsy

D) Obtain Anti-Streptolysin O titer

E) Furosemide

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