Pediatrics

Pediatrics A 4-month-old male is brought to your office for evaluation of “bloodshot eyes” of 2 days’ duration. He is otherwise well. He was born at 35 weeks gestation, weighed 2550 g (5 lb 10 oz), and was discharged the day after his birth. He has received well child care and immunizations at the local public health clinic. Examination confirms bilateral subconjunctival hemorrhages. Except for moderate irritability, the remainder of the examination is unremarkable. There is no known family history of bleeding disorders. An urgent evaluation by an ophthalmologist is requested, and it reveals bilateral retinal hemorrhaging. Which one of the following is the most likely diagnosis’ a) Acute thrombocytopenia, cause to be determined b) Hemophilia, type to be determined c) Retinopathy of prematurity d) Nonaccidental trauma e) Childhood glaucoma The Correct answer is D Explanation Infants who are shaken may have shaken baby (shaken impact) syndrome. This syndrome is caused by violent shaking, often followed by throwing the infant. Infants who are shaken may have no visible signs of injury and may appear to be sleeping deeply. This sleepiness is due to brain damage and swelling, which may result from bleeding between the brain and skull (subdural hemorrhage). Infants may also have bleeding in the retina (retinal hemorrhage) at the back of the eye. You are conducting a routine physical examination on a 6-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 a) Reassure the parents that the testicle will like descend in the next few months b) Order pelvic ultrasonography c) Order serum testosterone, LH, FSH, and müllerian inhibiting substance levels d) Refer the patient to a urologist e) Monitor the patient and refer only if the testicle does not descend by 2 years of age The Correct answer is D Explanation This patient most likely has an undescended right testicle, which needs to be addressed as soon as possible, certainly before the child reaches 2 years of age. Testes that have not descended by 6 months of age are unlikely to descend. Pelvic ultrasonography, with or without the noted hormonal studies, is appropriate only when testicles are bilaterally absent. A 1-year-old child presents to the emergency room with a 3-day history of dehydration. Physical examination of the infant is consistent with 10% dehydration. Serum sodium level is 165. All of the following about hypernatremic dehydration are true EXCEPT: a) Subdural hematomas may occur as a result of hypernatremia b) Hypernatremia may be caused when improperly mixed formulas are used c) Normal saline boluses should be given until the infant is stable d) Fluid should be given to rapidly reduce the serum Na in less than 24 hours e) Hypernatremia is seen in about 10-15% of patients with diarrhea The Correct answer is D Explanation Hypernatremic dehydration is seen in about 10-15% of patients with dehydration. The serum sodium level should be lowered slowly, no faster than 10-12 milliequivalents in 24 hours, due to the risk of cerebral edema and seizures. A. Subdural hematomas may occur due to intracellular fluid loss. B. Hypernatremia may be seen with improperly mixed formulas. C. 20cc/kg normal saline or lactated ringers fluid boluses should be given until the infant is clinically stable. E. Hypernatremia is seen in 10-15% of patients. A 5 year old boy is admitted with a provisional diagnosis of acute renal failure. The laboratory calls you to report that his serum potassium level is 7.5 mmol/L. Which one of the following should be your next investigation? a) Electrocardiogram b) Serum creatini