A 3-week-old baby boy has been having non-bilious vomiting after feeds. There is a palpable mass at the margin of his right rectus abdominus muscle.
Which of the following presentation patterns and treatments best applies?
Correct Answer E: Diagnosing and managing the cause of vomiting in the newborn period requires a good understanding of the signs and symptoms of the most common causes (tracheo-esophageal fistulae, duodenal atresia, pyloric stenosis and intestinal malrotation).
a) Tracheoesophageal fistula: A history of vomiting, coughing, gagging and /or cyanosis on feeding +/- recurrent pneumonia. X-ray will show abnormalities and an NG tube curled into a pouch. Treatment is surgical (tracheo-esophogeal repair).
b) Duodenal atresia: There is a higher incidence in premature births, or children with Down syndrome. History of bilious vomiting (which may eventually lead to hypochloremic metabolic alkalosis); air fluid levels and/or double-bubble on x-ray. Surgery is required.
c) Intestinal malrotation: recurrent vomiting (bilious intermittently), distended abdomen, complications such as perforation and peritonitis can lead to shock. Surgical emergency.
d) Objects swallowed or choked on would not likely be palpable.
e) Pyloric stenosis: History of forceful non-bilious vomiting in a newborn; can be detected as a palpable “olive” shaped abdominal mass, leads to a pattern of hypochloremic metabolic alkalosis and requires pylorotomy.
PEARL: Pyloric stenosis is suggested by a history of non-bilious vomiting in a newborn and an abdominal mass on exam.
A 11-year-old girl complains that one of her breasts is much larger and firmer than the other. These differences were confirmed by examination with no palpable mass. No nipple retraction was seen.
Which one of the following is the most appropriate management?
Correct Answer D: The most common abnormality seen in a primary caregiver’s office in children younger than 12 years is a unilateral breast mass corresponding to asymmetric breast development. One breast commonly develops earlier than the other. Ultimately, the breasts are symmetric, despite the discrepancy in the initial development.
Breast asymmetry may develop as thelarche ensues. In this condition, one breast may develop before or more rapidly than the other. The physical examination findings usually include homogeneous enlargement of one breast with no discrete masses or discharge. Accompanying breast tenderness may be present if the breast bud is starting to develop. If a mass is excluded either by physical examination or ultrasonography, the patient and parents can be reassured that the asymmetry will become less noticeable with age.
The most likely complication of an un-descended testis is:
Correct Answer C: Cryptorchidism is defined as failure of the testis to descend from its intra-abdominal location into the scrotum. Incidence in premature male infants is 9.2-30%. In full-term infants, the incidence is 3.3-5.8%, and in infants aged 1 year, it is 0.8%.
The lifetime risk of death from testicular malignancy in men of any age with un-descended testis is approximately 9.7 times the risk in men with normally descended testis.
Malignant degeneration: Testicular malignancies occur in 10% of men with cryptorchid testis. The incidence of malignant degeneration in an un-descended testis is reportedly as high as 48 times greater than in a normal testis. Seminoma is the most commonly reported malignancy.
Torsion is a rare condition, if present, usually is secondary to the presence of a mass.
You are conducting a routine physical examination on a 4-month-old infant who is new to your practice. The examination is entirely normal except that you do not feel a testicle in the right scrotal sac. You do, however, feel a soft, round, mobile mass high in the right inguinal area. It cannot be brought down into the scrotal sac with gentle maneuvers.
The most appropriate action would be to:
Correct Answer A: This patient most likely has an un-descended right testicle (cryptorchidism), which needs to be addressed as soon as possible, certainly before the child reaches 1 year of age. Testes that have not descended by 12 months of age are unlikely to descend. Descent can preserve spermatogenesis if performed by 1yr of age; untreated bilateral cryptorchidism: - 100% infertility. The choice of initial treatment is a reflection of the preference of both physician and the patient or the patient’s caretaker.
→ Pelvic ultrasonography (choice B), with or without the noted hormonal studies, is appropriate only when testicles are bilaterally absent.
→ For unilateral un-descended testis without hypospadias, no laboratory studies (choice C) are needed.
→ Hormonal therapy (choice D) not proven to be of benefit over standard surgical treatment
A 12-month-old child is brought by the father with 2nd degree burns on both hands. He tells you that the child dipped his hands in very hot bathtub water. There is a clear distinction line on the burn with no splash burns.
The most likely diagnoses is:
Correct Answer A:
This is most likely a case of child abuse. Common signs of such include:
Scald marks on the hands, feet or buttocks with a glove, sock or circular appearance are almost always caused by deliberate immersion.
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