[dr.Ira]

Explanation:

The correct answer is D. This boy has a minor closed head injury with no loss of consciousness, which is one of the most common injuries in children. All children "bump" their heads at some point. It is important to do a physical examination, including a complete neurologic and funduscopic examination, and if this is normal, be able to recognize that further studies are generally not indicated. Regular monitoring and observation for any abnormalities can be done by a competent caregiver. If this occurred during the day, you may consider having them stay in your waiting room for a little while, but since you are leaving for the night and the mother has always been responsible and compliant, you can send them home for observation.

It is inappropriate to advise them to go to the emergency department for observation (choice A). This child had a minor head injury with no loss of consciousness and he has a normal neurologic and funduscopic examination. It is very unlikely that he has an intracranial injury, and therefore, as long as you know that the mother is a competent caretaker, you should send them home after advising her to seek assistance if he begins to deteriorate.

It is unnecessary to obtain a skull radiograph (choice B) at this time in this child with a minor closed head injury without a loss of consciousness. He does not have any signs of a skull fracture, which include battle signs (ecchymoses behind the ear), a palpable depression, or blood in the ear and therefore it is very unlikely that the radiograph will show a skull fracture. Also, even if he did have a skull fracture that does not necessarily mean that he has an intracranial injury.

A CT scan (choice C) is not indicated at this time in this patient with a minor closed head injury, no loss of consciousness, and a normal neurologic and funduscopic examination. Studies have shown that the risk of intracranial injury is negligible in this situation, and that fewer than 1 in 5,000 patients with minor closed head injuries and no loss of consciousness have intracranial injuries that require medical or neurosurgical intervention.

Since this case states that they are very healthy and compliant patients and the physical exam does not reveal any abnormalities besides this head wound that seems consistent with the story the mother told you, it is inappropriate to report the case to the child protective service agency (choice E). It is always important to be aware of signs of child abuse, such as many emergency room visits, many wounds in various stages of healing, implausible and inconsistent stories, and bringing the child in a while after the injury took place. This case does not seem to fit this description