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Unformatted text preview: Week 9 Case 2 Jacob is a 1.5 weeks old brought in by his distressed mother. While changing his diaper last night, she
noted that his penis was edematous and erythematous. He has been crying and fussy. Per mom, no
other complaints. She's been breastfeeding every 1-2 hours without any issues. PE: Stable VS and growth patterns. Essentially a normal examination except a slightly erythematous and
edematous glans penis with retracted prepuce. Questions for mother Has there been any drainage from the penis?
Has it felt warm to touch?
Does he cry when his penis is touched?
When he urinates does he appear uncomfortable or cry?
Does he appear to have difficulty with urination?
Has he had a temperature?
Primary diagnosis Balanitis: This would be my primary diagnosis in this case scenario. Balanitis is swelling and inflammation
of the glans penis. Predisposing factors include poor hygiene and over washing, use of over-the-counter
medications, and non-traction of the foreskin (Edwards, Bunker, Ziller, & Meijden, 2014). The foreskin
harbors bacterial and irritates the glans penis. Normal skin flora is the source of the infection.
Streptococcal balanitis is a rare clinical entity, with the peri-anal region being the predominant site of
perineal Streptococcus pyogenes infection in boys (Randjelovic et al., 2016). If there is urethral
discharge patients should undergo testing for a sexually transmitted disease. This patient is not in the
age range that you would consider this as a possibility unless child abuse is suspected. Differential diagnosis Contact dermatitis: This a probable differential diagnosis for this patient. A thorough history from the
mother would be essential to rule out this possibility. There could be a possibility that the child could
have an allergy to his diapers. If the diapers were cloth ask if they have recently changed laundry
detergents. Inquiring with family to see if they have been applying any lotions or ointments to his penis. The key to treatment for contact dermatitis is to remove the allergen. After this is done no further
treatment is required. Seborrheic dermatitis: Patients have erythematous and greasy scaly patches. Circumscribed patches are
found on the scalp, glabella, nasolabial fold, posterior auricular skin, and anterior chest. The most
common area involved in the scalp. For this patient, there isn't any description of scaling plaques around
the penis. Lichen sclerosus: Lichen sclerosus (LS) is a chronic inflammatory dermatosis characterized by altered
fibroblast function in the papillary dermis leading to fibrosis of the upper dermis (Folaranmi, Corbett, &
Losty, 2018). LS is a chronic atrophic dermatitis with unknown etiology. LS is characterized by white
atrophic plaques that may affect the foreskin, glans penis, frenulum, and meatus or urethra in males. It
many times also causes phimosis. In the above case scenario, it was listed that the foreskin was retracted
exposing the glans penis. There is also no mention of white plaques which is a common physical finding
in this disorder. It would make this an unlikely differential in this case. Testing A culture swab of the penis should be done for culture and sensitivity. Gram stain testing should also be
performed. That would aid the provider for proper treatment of a bacterial infection or a Candida cause.
If antibiotics were required this would ensure that the bacteria was susceptible to the medication
prescribed. Treatment Treatment would consist of topical antibiotics and topical steroids. Bacitracin is an effective over-thecounter (OTC) agent that is applied two to three times a day. The swelling doesn't appear to be
significant enough to place the patient on systemic antibiotics at this time. Topical antifungal creams
such as clotrimazole, miconazole nitrate, terbinafine hydrochloride, and tolnaftate are all safe and over
the counter. Application to the affected area twice a day. This would only be used if it was identified as a
fungal infection. Parental education Educating parents to bathe the child in warm soapy water would be a good start. Also, thoroughly drying
the child. Retracting the foreskin is essential for good hygiene. The skin should never be forced and could cause trauma. In uncircumcised males, there is only concern with phimosis if there is recent infections or
urinary obstruction. Circumcision is rarely needed, and this condition resolves on its own as the child
matures. Reassurance of the mother will be beneficial alleviating fears that her son's penis will continue
to grow and develop normally. Immunizations Pt should have received first his first dose of Hepatitis B before discharge from the hospital. The next
well-child visit would occur at 1 month. The only vaccine due at this visit would be the 2nd dose of
Hepatitis B. Anticipatory guidance There are many new and exciting behaviors that the mother should anticipate when she comes back for
the 1-month visit. The child will begin to turn his head to the side when in a supine position. When his
arms are brought to his face, he will make a fist. While being fed, he should exhibit a good suck reflex.
The mother should notice he recognizes her face. References Edwards, S., Bunker, C., Ziller, F., & Meijden, W. I. (2014). 2013 European guideline for the management
of balanoposthitis. International Journal of STD & AIDS, 25(9), 615-626. doi:10.1177/0956462414533099 Folaranmi, S. E., Corbett, H. J., & Losty, P. D. (2018). Does application of topical steroids for lichen
sclerosus (balanitis xerotica obliterans) affect the rate of circumcision? A systematic review. Journal of
Pediatric Surgery, 53(11), 2225-2227. doi:10.1016/j.jpedsurg.2017.12.021 Randjelovic, G., Otasevic, S., Mladenovic-Antic, S., Mladenovic, V., Radovanovic-Velickovic, R.,
Randjelovic, M., & Bogdanovic, D. (2016). Streptococcus pyogenes as the cause of vulvovaginitis and
balanitis in children. Pediatrics International, 59(4), 432-437. ...
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