A four-year-old boy is brought in by his mother for 3 weeks of abdominal pain, having been to two other EDs this week, diagnosed with constipation.  She brings him in today because now he has two days of “red urine”.  No fever, nausea, vomiting, or diarrhea.  He is eating well.    T 37.9 HR 100 100/60 RR 22 100% RA.  He has no tenderness to palpation on abdominal exam, but has what appears to be a left flank-abdominal mass.  While he is waiting to be registered, his mother notes that he is “acting funny – why is he so tired?”.  You re-examine him to find an altered young boy, diaphoretic, HR 120.  Which of the following is the best choice for immediate intervention?      
    A.   Initiate fluid resuscitation with 20 mL/kg IV bolus over five minutes
    B.   Give 3 mL/kg of 10% dextrose and monitor
    C.   Give Tylenol 15 mg/kg PR and re-assess
    D.   Give 2 mL/kg 25% dextrose and monitor  

In the meantime, a quote --   "Medicine is not a field in which sheep may safely graze."


bailey roche
10/29/2012 11:27am

I'm thinking the answer is A. It sounds like this is a Wilms Tumor, given the abd pain, hematuria, and palpable flank mass. I wonder if this is a renal capsule rupture from over-vigerous palpation (or repeated exams -- this kid was examined several times). Can't think of a reason why he would go suddenly hypoglycemic... and this doesn't sound like a febrile seizure (hasn't been febrile) so I don't think I'd give tylenol.


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