WBR0433

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Behavioral Science/Psychiatry
Sub Category	SubCategory::Dermatology
Prompt	[[Prompt::A 5 month old female patient is brought to you by her parents because they are worried she has bruises over her body. Otherwise, they report that they are completely satisfied with the way their daughter is growing. You are worried if the parents are saying the truth and thus you ask that you do a full physical examination of the patient. Upon examination, you note the following lesions on the patient’s back as shown in the image below. Otherwise, physical examination is unremarkable. Which of the following is the best next step in your approach towards this patient? ]]
Answer A	AnswerA::Reassurance
Answer A Explanation	[[AnswerAExp::In the context of a normally growing infant that does not appear to have any abnormality, the physician is only required to reassure the patient’s parents because generally, Mongolian spots disappear by early childhood.]]
Answer B	AnswerB::Calling the police
Answer B Explanation	[[AnswerBExp::Although child abuse, which requires immediate calling the police, should always be in the differential diagnosis of Mongolian spots, child abuse would not cause such characteristic bluish-lesions despite their resemblance to traumatic bruises. Child abuse can have more symptoms also, such as multiple fractures of different ages, retinal hemorrhages, subdural hematomas, etc… all of which are not present in this child. In the case of child abuse, the infant care may probably be compromised as well and the development of the child may be delayed.]]
Answer C	AnswerC::Performing x-rays
Answer C Explanation	[[AnswerCExp::Further testing is not required for patients with Mongolian spots who are otherwise healthy.]]
Answer D	AnswerD::Genetic testing
Answer D Explanation	[[AnswerDExp::Further testing is not required for patients with Mongolian spots who are otherwise healthy.]]
Answer E	AnswerE::Bone marrow biopsy
Answer E Explanation	[[AnswerEExp::In the case of a hematologic malignancy that can cause thrombocytopenia and easy bruising, a bone marrow biopsy is indicated; but the child is not expected to be growing with normal development.]]
Right Answer	RightAnswer::A
Explanation	[[Explanation::The patient’s physical examination is consistent with Mongolian spots or congenital dermal melanocytosis. It is characterized by one or many benign bluish patchy self-limited lesion(s) that is/are very common in infants and typically is/are located at the lower back region, the buttocks, and/or the shoulders. The condition results from entrapped melanocytes in the dermis because of inhibited neural crest cell migration to the epidermal layer. Diagnosis is only clinical. Further work-up in an otherwise healthy child is unnecessary and treatment is not needed because the lesions are self-limited. The physician should reassure the patient’s family about the benign condition. Educational Objective: Mongolian spots are benign patchy self-limited lesions that are very common in infants. They are a clinical diagnosis and require no treatment. References: Cordova A. The Mongolian spot: a study of ethnic differences and a literature review. Clin Pediatr (Phila). 1981;20(11):714-9.]]
Approved	Approved::No
Keyword	WBRKeyword::Mongolian spot, WBRKeyword::child abuse
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