A teenaged boy complains of a lump in his forearm.
It has been there for three weeks and is growing rapidly.
He also complains that he is having trouble urinating or having bowel movements,
and reports of seeing blood in his urine.
The boy's mother also noticed that in the past couple of weeks he was having a lot of
nose bleeds. The mother began to worry about him and decides to take him to your office.
On questioning, the patient
reports of having considerable pain over the past few weeks
in the region of his left eye. He thought this was a headache, and was taking acetaminophen
to try to control the pain.
He was also experiencing general symptoms of weakness, fatigue, fever, and loss of appetite.
Past medical history is remarkable for known Neurofibromatosis Type 1,
diagnosed by a geneticist who saw him because his father also has the disease.
His past surgical history includes a fracture from a bicycle accident.
He is not taking any prescribed medications.
The teenage boy also takes Flinstone vitamins once every morning.
He does not smoke, he does not drink alcohol, and he does not use recreational drugs.
Physical exam reveals that the left eye protrudes slightly forward.
("Gosh. I did not notice that.") There is a 4 cm soft slightly tender mass
on the centar of the palmar aspect of the left forearm.
There are several large freckles in each armpit, and several soft slightly elevated nodules
on the face and trunk, none greater than 6 mm.
He has normal heart and bowel sounds. Temperature is 99.9 F, pulse 58,
respiratory rate 11, blood pressure 120/80. No other pertinent physical findings.
This is a real patient, by the way.
All of the follow entities are worth considering. Which ones do you think are most likely?