Pediatrics Answers 423treatment with aspirin is recommended both for its antiplatelet and anti-
inflammatory effects.
Although this patient will require a cardiology consultation (a), it is not
the next step in management as it is critical to delay treatment. There are no
laboratory values which contribute to making the diagnosis, although there
are some characteristic findings. Typically these patients have elevated
serum markers of inflammation, ESR and CRP. The other classic finding is a
thrombocytosis which typically doesn’t present itself until at least a week
into the disease and can reach over 1 million/mm^3 in some cases. Additional
laboratory tests (b)are not required except in cases where the diagnosis is
in question. Therefore, answer choices (c), reassurance, and (d), continued
septic workup, are incorrect.
376.The answer is d.(Fleischer and Ludwig, pp 727-728.)The most
important next step is administration of prostaglandin bolus followed by
a drip.This patient is in severe cardiac failureresulting from impending
closure of his ductus arteriosus.The patient is presenting in a classic
time frame, approximately 4 to 7 days after birth. Ductal-dependent con-
genital heart lesions that present in this manner typically include transpo-
sition of the great arteries, truncus arteriosus, total anomalous pulmonary
venous return, left heart hypoplasia, and coarctation. The most important
next step is administration of a medication that will assist the ductus to
remain open while preparing for surgical intervention.
Oxygen(a)is a stimulant to close the ductus (as is appropriate in nor-
mal infants) and should not be administered, though this patient will likely
need to be intubated to take away his work of breathing and because
prostaglandins can cause apnea. The other choices, (b)chest radiograph
and ECG, (c)antibiotics and full sepsis workup, and (e)cardiology con-
sultation, would all likely need to be done. However, the patient requires
immediate intervention with prostaglandin.
377.The answer is b.(Fleischer and Ludwig, pp 1616-1617.)This patient
haspyloric stenosis, and will exhibit a hypochloremic, metabolic alkalosis
with hypokalemia.Hypoglycemia is common in children this age who
experience poor intake of calories and who have very poor glycemic
reserves. The low chloride and high bicarbonate are the result of hydrochlo-
ric acid loss from stomach with repeated episodes of vomiting leading to an
alkalemia. As a result, the patient will physiologically try to balance ions and
trade intracellular H+for extracellular K+, thus lowering the serum potassium.