A 6-Year-Old Boy Is Brought to the Office for a Routine

A 6-year-old boy is brought to the office for a routine health maintenance examination.  Several "dark spots" on his trunk have been increasing in number and now appear to be spreading.  The skin lesions are not painful or pruritic.  The patient has no chronic medical conditions and takes no medications.  He has reached all developmental milestones and is in the first grade.  Maternal family history is noncontributory.  The parents are divorced and paternal history is unknown.  Blood pressure is 98/64 mm Hg and pulse is 100/min.  The patient is at the 25th and 50th percentile for height and weight, respectively.  Examination shows an alert, active boy.  Pupils are equal and reactive bilaterally.  Cranial nerves II-XII are intact.  Cardiac examination reveals a regular rate and rhythm; no murmurs are auscultated.  The abdomen is soft and has no palpable masses.  Scattered 1×2 cm, hyperpigmented macules are seen over the trunk, left arm, and right thigh, as shown in the exhibit, and numerous 2×3 mm, hyperpigmented macules are seen in the bilateral inguinal creases.  The patellar and Achilles deep tendon reflexes are 2/4 bilaterally.  Muscle bulk and tone are normal in all extremities.  Which of the following is the best next step in management of this patient?

A) Audiologic evaluation
B) Biopsy of the skin lesions
C) Ophthalmologic evaluation
D) Reassurance and observation
E) Serum growth hormone level

Correct Answer:

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