1 March 2010
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
-Ken
Dear Ken: If you told me that you see a foreskin coming to a point over the tip of the penis, or that you cannot retract the skin to reveal the head of the penis I would say that is a problem (but I cannot envision that as the end result of a circumcision). Before puberty the penis remains small. Infants often have a heavy pubic fat pad in which the penis can easily become buried. This pushes skin from the shaft of the penis over the top. It is perfectly normal. If you put a finger on either side of the penis and press down into the pubic fat pad, not only will you appreciate how much of the shaft of the penis is buried in the fat pad, but the head of the penis will probably come out from under the cover of the skin pushed over it without your having to retract the skin.
Sincerely,
Dr. Warren
Thank you!
-M&JM
Dear M&JM: The periodicity of your son's fevers and his apparent good health between fevers is certainly consistent with FAPA (or PFAPA) - (Periodic) Fever, Aphthous stomatitis, Pharyngitis, cervical Adenitis. What I can tell you about PFAPA is that it is a clinical diagnosis. There is no test to establish the diagnosis. To make a diagnosis of PFAPA, all other possible causes of the symptoms must be excluded and the symptoms must meet all the criteria for diagnosis which includes not only recurrent or Periodic Fever, but also Aphthous stomatitis [mouth sores], Pharyngitis, and Adenitis [swollen glands]. While it may not be possible to be sure if your son has a sore throat, it should be possible for your doctor to tell if he has pharyngitis; however, pharyngitis is such a common part of viral upper respiratory infections, that it's presence would not be conclusive. What strikes me as I read your e-mail is that you don't mention mouth sores. Your doctor should certainly be able to find them if they are present, and after this many mystery illnesses, if mouth sores were part of the picture, the pattern would have been evident. Since FAPA is in itself a rare entity, it would be hard to consider a forme fruste (incomplete presentation) of FAPA, especially when it is a clinical diagnosis which depends on the presence of it's defining characteristics, which includes the mouth sores.
The cause of FAPA remains unknown. While there are research articles on treatment, as far as I know, no standard treatment regimen exists. The natural course of the condition appears to be that it goes into remission where eventually the recurrences cease. In any event, your son requires a diagnosis before treatment is an issue. The definition of FAPA not only includes the clinical criteria, but also, that all other possible causes be ruled out. To that end, you should proceed with a complete evaluation of your son's immune system and possibly consult an infectious disease specialist and a rheumatologist. The reason for considering the rheumatologist is that inflammatory diseases may also be a cause of undiagnosed fever.
Sincerely,
Dr. Warren
The first time it happened on Thursday in the middle of the night (I did not take her temp, but her hands and body were very hot to the touch, so I gave her some Motrin and she went to sleep).
Friday she was fine most of the day but by 4 or 5 she was feeling it again but not so bad she could not move. Friday night she slept fine, and all day Saturday she was fine.
Then she woke up around 6 am on Sunday and could not move. She was crying, in a lot of pain and again was very hot to the touch, her temp was about 100.3. I called her doctor and he suggested the emergency room, just to be sure.
The ER doctor threw back the curtain and said it's a pulled muscle - he didn't talk to me, run one test or even look at her. I was very disappointed in this diagnosis, but I tend to trust my doctors, so I gave her Motrin and took her home. The Motrin helps, I can't deny that but once it wears off the temp comes back.
I should also mention at this point that she also had an ear infection and a rash all over her entire groin area, which she always gets when she has strep throat (she does not have a sore throat, but she also had her tonsils removed in February of this year). The doctor ignored my motherly instinct and told me it was a contact rash and that it and the ear infection would go away by it self.
Well, by Tuesday the ear hurt worse, the rash was worse and she was consistently running a low grade temp, so I took her to her doctor. She told me exactly what I told the ER doctor, the rash is consistent with a strep rash and the ear infection is not the kind that goes away by itself. She has been on an Antibiotic for one day.
So, here is the problem, last night she woke up again with the leg pain. She could hardly get out of bed or even walk around. I gave her Motrin (we have finished a whole bottle at this point) and she is moving around a little more. My question is, what are her symptoms consistent with? Could she have a swollen gland in her thigh area that is being affected by the strep because she has no tonsils? What could the leg pain be and what kind of tests should I request be done (if any)?
Any help would greatly appreciated!
-AZ
Dear AZ: There are a few pieces of information I would have liked to be sure of the best answer to your question;
Your doctor might want to do blood work to check for Lyme disease and rheumatic disorders. Your daughter should probably be evaluated by an orthopedist. An x-ray of the hip and thigh would be a reasonable first test. Other studies such as an MRI or bone scan might be appropriate depending on the orthopedist's findings.
Sincerely,
Dr. Warren
Did your daughter have a throat culture or rapid strep test?They did a throat culture.
Was the
diagnosis of strep confirmed? The results were positive.
What's happened to her fever? By the end of the day Tuesday, and an entire bottle of Motrin, her temp was gone and has not come back.
What is the timing of the current hip/thigh pain in relation to the
previous illness? By previous illness I am assuming you are talking about the ear pain, rash...the leg pain started a day or two before everything else
Your paragraph before it ended that she was on the
antibiotic for one day, but I wasn't sure if that applied to the chronology
of the next paragraph. The antibiotic was prescribed on Tuesday by her regular Doctor for the ear infection and strep.
What antibiotic is she on? Cefzil, she is allergic to penicillin.
-AZ
Dear AZ: Step throat and viral sore throats are known to cause inflammation of internal lymph nodes, even if tonsils are present; however, if swollen glands in the groin (which I have not heard of from strep) were responsible for your daughter's pain, she should have palpable tender nodes in the groin.
Muscle aches can be seen with any illness, but if your daughter always has pain localized to the same thigh, she deserves orthopedic evaluation to rule out any pathology in the hip joint or femur (the thigh bone). This would include an examination by an orthopedist, possible blood work and scans as mentioned in my previous response. Because of the recurrent nature of your daughter's pain and it's apparent association with other illnesses, if the orthopedist does not provide an answer, you might consult a rheumatologist.
Sincerely,
Dr. Warren
-(unsigned)
Dear 14 Year Old: It is possible, based on all the important things going on in your life right now, that these are stress symptoms. It is equally possible that inadequate sleep and nutrition could contribute to your problem. Two weeks is a bit long to experience symptoms from an infectious illness, although your symptoms could have started from one. The bottom line is that I can't tell you what you have without examining you and perhaps running some tests, and more important, I can't treat your symptoms by e-mail, even if I had a good idea what's going on, so you need to see your doctor.
Sincerely,
Dr. Warren
Thank you.
-21 Girl
Dear 21 Girl: You don't have to have had sex to know about birth control, and I think it's important for you to get fully educated about it so that you know what your options are and understand the risks and benefits to each choice. Unfortunately, most of the burden falls on women since the only effective birth control for men is condoms; however, your fiancé should join you in becoming educated about the options since no method is fool proof, and you may want or need to change your method of birth control down the road.
An injection of Depo-Provera is an option for you, but you can't wait until the night before the wedding since it has to be given at an appropriate time during your cycle. Then it must be given every 3 months. Birth control pills or patches are also an option. To be effective, you must not miss any doses, and must complete one full cycle before you are protected. A diaphragm can be used with a spermicide just at the time of intercourse, but even that requires a doctor visit for a fitting. The bottom line is that you need to see a gynecologist in a private office or a family planning clinic like Planned Parenthood, and you need to do it now. You can't wait until just before the wedding.
Sincerely,
Dr. Warren
-JR
Dear JR: Your child has undoubtedly already had a significant amount of evaluation by the feeding clinic, gastroenterologist, and pediatrician. Even if I were privy to all the results of her evaluations and had examined her, it is not likely that I would have a better idea than all the other doctors how to proceed. However, in spite of the fact that all evaluations so far have not yielded any answers and other evaluations are planned, it is possible for your daughter's condition to be tipped over the edge by an additional intercurrent illness. If you are finding that your daughter seems sicker to you and you feel she is in danger, she must be evaluated now to determine her current status. Future plans for evaluation are irrelevant if your child is acutely ill.
If your doctor has seen your daughter since her overall condition has deteriorated and feels that she is not in any danger, it may be okay to wait, but if you don't trust your doctor's opinion on your daughter's current status, forget the issue about further specialty evaluations and testing and get another opinion regarding her current status ASAP, even if that means going to an emergency room or going to another pediatrician. If your doctor has not even seen your daughter since her condition deteriorated, contact him immediately, and focus on her current status, not plans for future evaluation.
Sincerely,
Dr. Warren
Can you help me out with this?Thanks...
-Ms. S
Dear Ms. S: Whenever a patient has persistent vomiting, it is necessary to put the stomach to complete rest for at least a day in order for the vomiting to resolve. That means the patient cannot have any food or milk and should only drink clear fluids, preferably an electrolyte solution like Pedialyte. The amount of clear fluid given should be small and gradually increased. That is the principle of how to manage vomiting; however, since your daughter has other symptoms and you do not know the cause of her vomiting, while I do recommend that you follow my advice regarding feeding, I also suggest that she see her pediatrician.
Sincerely,
Dr. Warren
-ME
Dear ME: Most hemangiomas are small capillary growths in the skin which shrink down, usually by two years of age. They can be treated with laser, but it is generally advisable to delay treatment until the hemangioma has involuted (shrunk) in order to have the best scar. Many will shrink enough so that no treatment is required. Hemangiomas are soft and so not generally any more prone to injury than the surrounding tissue. Since they are capillaries, blood loss can generally be controlled with gentle pressure just like with any cut. Serious blood loss through the typical strawberry hemangioma is unheard of.
You will note that I said things like "most" and "typical." While I want to provide you with adequate reassurance, I don't want to be negligent and portray all hemangiomas as benign. If your doctor has reassured you, then you can be sure that your daughter's hemangioma fits the picture above, i.e., nothing to worry about. Hemangiomas can be a problem when they are large, when they are internal, and when they obstruct important organs like the eye or throat. The presence of a small hemangioma on the forehead does not indicate any such problem.
Sincerely,
Dr. Warren
Dear Readers: Treatment of hemangiomas by laser should be left until the hemangioma has involuted [shrunken naturally] for the best cosmetic result. This usually takes until at least 2 years old.Sincerely,
Dr. Warren
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