Problem Solving In Pediatrics
Case 1
A 12 months old boy presents to the emergency department with a 6 hour history of vomiting, colicky abdominal pain, and irritability. On physical examination a sausage like mass is palpable in the right upper quadrant of the abdomen What is the most appropriate next step in management?
A. Order a CT scan of the abdomen
B. Order a barium swallow
C. Obtain a surgical consultation
D. Follow up examination after 4 hours
Choice A : a. Points against: time and money wasting + not method of choice, ultrasound is better.
Choice B: a. Points against: shows till duodenum while obstruction is in upper Rt quadrant + baby suffers
from vomiting b. If we were to use this method, we'd use barium enema
Choice C: (the right choice) a. Points with: 1. Age of boy, intussuception usually occurs between 6 months
to 3 y.o. (usually after gastroenteritis) 2. Sausage like mass ( CANT possibly be liver) 3. Since known intussuception, early management is very easy [reduction by pressure] using air Choice D: a. Points against: sausage like mass suggests intussuception, if the last sentence was not in the case this would have been the right choice [hospital admission with regular check up every hour]
b. If a case of intuss. Is left without ttt, it proceeds to gangrene and death, with management necessitating surgical intervention, which would not have been required if managed early (reduction by pressure using air)
