A year-old child presents with abdominal pain. He is drawing his legs up, bloody mucus in seen in his stool. A sausage shaped mass is palpated in his abdomen.
What is the most likely diagnosis?
Correct Answer D:
Intussusception is telescoping of one portion of the intestine (intussusceptum) into an adjacent segment (intussuscipiens), causing intestinal obstruction and sometimes intestinal ischemia.
Intussusception generally occurs between ages 3 months and 3 years, with 65% of cases occurring before age 1. It is the most common cause of intestinal obstruction in this age group, in whom it is usually idiopathic. In older children, there may be a “lead point,” ie, a mass or other intestinal abnormality that triggers the telescoping; examples include polyps, lymphoma, Meckel's diverticulum, and Henoch-Schönlein purpura. Cystic fibrosis is also a risk factor.
The telescoping segments obstruct the intestine and ultimately impair blood flow, causing ischemia, gangrene, and perforation.
The initial symptoms are recurrent colicky abdominal pain that occurs every 15 to 20 min, often with vomiting. The child appears relatively well between episodes. Later, as intestinal ischemia develops, pain becomes steady, the child becomes lethargic, and mucosal hemorrhage causes heme-positive stool on rectal examination and sometimes spontaneous passage of a “currant jelly” (blood mixed with mucus) stool. A palpable abdominal mass, described as sausage-shaped, is sometimes present.
A healthy 8-month-old white male has suddenly developed recurrent bouts of what appears to be severe abdominal pain. He cries inconsolably and draws up his legs, but does not seem ill between episodes. He has vomited and on examination has a small amount of bloody mucoid stool in his diaper and palpable mass in his un-distended right upper abdomen.
The most likely diagnosis is:
Correct Answer A:
This case presentation is fairly typical for intussusception, the “telescoping” of a portion of the intestine into itself with obstruction and crampy pain. it generally occurs between the ages of 6 months and 24 months. A sausage-shaped mass is often palpable as a result of the ileum being trapped within the colon. The presence of bloody mucus supports the diagnosis.
→ Pyloric stenosis generally occurs in the first 4-6 weeks of life (although it can occur as late as the fifth month) with a striking first-born male predominance. Emesis is the most prominent feature of pyloric stenosis; it is usually painless, and there are no bloody stools. The small pyloric mass, which feels like an olive, may be palpable at the margin of the right rectus muscle. The onset is more insidious than with intussusception.
→ Duodenal atresia presents shortly after birth with vomiting and a “double-bubble” on radiograph, indicating a gas-filled stomach and proximal duodenum.
→ A Meckel’s diverticulum may rarely be found at the lead point of an intussusception, but it usually presents as a cause of recurrent abdominal pain in later life.
→ Gastroschisis is an antenatal evisceration through a small paraumbilical defect that is present at birth.
A child presents with the following rash:
You diagnose her with impetigo.
What is the most appropriate treatment?
Correct Answer B:
Impetigo typically presents as clusters of vesicles or pustules that rupture and develop a honey-colored crust (exudate from the lesion base) over the lesions. Treatment for localized disease is topical mupirocin. Oral such as dicloxacillin or cephalexin are also used.
A 3-year-old male is brought to your office because of a slowly spreading rash on his face of several days’ duration. The mother states that he is otherwise healthy. Examination shows a 2-cm area of yellow crust on his right cheek. There is no surrounding erythema. Examination of the nose and throat reveals normal findings.
Which one of the following would be the most appropriate treatment?
Correct Answer C:
Impetigo is caused by group A beta-hemolytic Streptococcus and/or Staphylococcus aureus, and is one of the most common skin infections in children. Even though it is thought to be self limiting, treatment is recommended because of its contagiousness.
Amoxicillin would not cover Staphylococcus, and sometimes it is difficult to get young children to take oral antibiotics. In addition, they increase the risk of antibiotic-associated diarrhea or allergic reactions. Mupirocin cream has been found to be just as effective as oral antibiotics in cases of limited infections.
A 5-year-old female presents with a lesion on her forearm. It began as a red macule, turned into a small vesicle that easily ruptured, then dried into a 1-cm honey-colored, crusted lesion seen now.
Which one of the following would be the most appropriate therapy?
Correct Answer E:
Topical mupirocin is as effective as cephalexin or amoxicillin/clavulanate in the treatment of impetigo. Oral penicillin V, oral erythromycin, and topical bacitracin are less effective than mupirocin. Topical disinfectants such as hydrogen peroxide are no more effective than placebo.
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