Course: WB 1105
CE Original Date: August 20, 2007
CE Renewal Date: August 20, 2010
CE Expiration Date: August 20, 2012
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This Initial Check will help you assess your current knowledge about lead toxicity. To take the Initial Check, read the case below, and then answer the questions that follow.
A father brings his two-year-old boy into a pediatrician's office for a routine well-child visit. From the father, the doctor learns that the boy's parents are divorced and that he generally lives with his mother and her parents. (The mother had to accompany her parents to her aunt's funeral this weekend and therefore could not make the appointment.) The doctor makes a note of this information.
The pediatrician examines the boy and finds no abnormalities. The boy's growth and development indicators are within normal limits for his age.
Three years later, concerned that her child is hyperactive, the mother brings the same child, now five years old, to your office (his previous pediatrician recently retired). At a parent-teacher conference last week, the kindergarten teacher said that the boy seems impulsive and has trouble concentrating, and recommended evaluation by a physician as well as by the school psychologist. The mother states that he has always seemed restless and easily distracted, but that these first six months in kindergarten have been especially trying.
He has also complained recently of frequent intermittent abdominal pains and constipation. The mother gave him acetaminophen for stomach pains with little change, and has been giving him a fiber laxative, which has reduced the frequency and severity of constipation. She wonders if the change to attending kindergarten has a role in his increased complaints.
Family history reveals that the boy lives with his sister, mother, and maternal grandparents in an older suburb of your community. The child visits with his father one weekend a month, which is working out fine. However, he seems to be fighting more with his sister, who has been diagnosed with attention-deficit disorder and is repeating first grade. Since the mother moved in with her parents after her divorce four years ago, she has worked with the grandfather in an automobile radiator repair shop, where her children often come to play after school. She was just laid off, however, and expressed worry about increasing financial dependence on her parents. She also worries that the grandfather, who has gout and complains increasingly of abdominal pain, may become even more irritable when he learns that she is pregnant.
Her third child is due in 6½ months.
On chart review, you see that the previous pediatrician examined the boy for his preschool physical one year ago. A note describes a very active four year old who could dress himself without help but could not correctly name the primary colors. His vision was normal, but hearing acuity was below normal according to a hearing test administered for his preschool physical. The previous doctor noted that the boy's speech and language abilities were slightly delayed. Immunizations are up to date.
Further history on last year's visit indicated adequate diet, with no previous pica behavior. Hematocrit was diminished at 30%. Peripheral blood smear showed hypochromia and microcytosis. There was no evidence of blood loss, and stool examination was negative for occult blood. The diagnosis was “mild iron deficiency anemia,” and elemental iron 5 mg/kg per 24 hours (three times daily after meals) was prescribed. The family failed to keep several follow-up appointments, but the child did apparently complete the prescribed 3-month course of iron supplements. He receives no medications at this time and has no known allergies.
On physical examination today, you note that the boy is in the 10th percentile for height and weight. The previous year he fell within the 20th percentile. His attention span is very short, making him appear restless, and he has difficulty following simple instructions. Except for slightly delayed language and social skills, the boy has reached most important developmental milestones.
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