Clinical Case 052: Belly, bum and balls…
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.
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
HSP?
?HSP
I’m thinking HSP with possible intussusception
Look for any rashes (GI complaints can precede rash) and do a U/A looking for red cells, casts
Abdo USS looking for intussusception +/- air enema
No particular tests for HSP but important to know coags and platelets
Also thinking HSP
Now here’s the question – steroids or not?
Recent case, classic HSP. Ended up admitted then discharged aft a week or conservative Rx. paeds advice ‘no roids’. Readmiired a few days later, bellyache +++ and transferred to tertiary centre. Pain +++. ketamine infusion, fentanyl for pain. Eventually given stoids – pain resolved!
Next time should I ignore paeds and give the steroids?
Spooky…havent seen HSP for a few years…then two cases recently and your post. So…the data on steroids seems equivocal. Given its a vasculitic process, giving roids seems intuitive.
Straw poll – who would give steroids? And who wouldn’t (anecdote-based medicine, but hey!)
Tim – I reckon I would give steroids for significant GI symptoms. What is the risk of a few days pred in this scenario?
Ignoring specialist advice is tough yet strangely satisfying sometimes.
You can always call another specialist to try and reach ” consensus ” if your patient isn’t winning after round 1!!
…absolutely!
I try to practice evidence-based medicine – but often it has to be anecdote-based medicine.
i just had a case of this 3 wks ago. i have many pics of the rash and the presentation. Would you like me to send to you?
child presented with joint pain and a rash “because of a many mosquitos”.
im always amazed by the mosquitos and spider bites that no one sees the insect?!