Today’s case is not in the ED. This one unfolds on the ward – the morning after the admission. So imagine yourself there – on the Paeds surgical ward.
6 year old boy was admitted last evening after referral from the local GP to the on-call Surg team.
He has a 24 hour history of increasing central abdominal pain. The pain wa initially periumbilical, but overnight it has localized to the lower abdomen – maybe a bit more on the right. Urinalysis was normal
The surgical team have been on their super-early orning rounds and seen the child – they have written in the notes:
“ tender lower abdo, no rebound, guarding, otherwise soft, afebrile. Bloods all normal. PLAN: Med team consult please.? epurients”
OK, now that is Surg -speak for – we aren’t operating on this kid – not a likely appendix. Turf to med, maybe its constipation?
Half way though your ward round the nurse- coordinator calls you to say: “You had better come see this kid – he has just had a bout of melena”
Hmmmm… not sounding like your average “un-appendix”. So you pop in and see him. Mum is looking worried. His obs are normal, his belly is ‘as described’ by the Surg team. When you pull down his jocks for a gander at his bottom you notice his scrotum is a bit red, and on examination his left testis is tender and there is a definite hydrocoele. Hmmmmm…
OK – can you solve this Paediatric puzzle?
What is going on? Well here is the clincher.
What are you going to do next?
Congrats to Dr Bek – who as it turns out practices about 500m down the road from me at the local Aboriginal Medical Service. Bek gave the right and most insightful answer. Good call from Maj and Patrick also – honorable commendations. I happen to know Bek was at a recent talk I gave which covered HSP – so technically she did cheat? But I think she already knew before I got to her!
Monitoring includes urinalysis testing, BP monitoring – as there is about a 7% recurrence rate and the risk of renal disease goes up with recurrence and older-age of the kid.