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Morning ReportEdward Fisher, MD PGY-2
November 21, 2012
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MJ, 4 yo boy
Setting: Emergency department
CCx: Abdominal pain
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MJ, 4 yo boy
HPI: R-sided abdominal/flank pain x12 hrs 1 episode of NB/NB
emesis
Normal stools, no diarrhea Small sediment in urine? Tylenol,
ibuprofen not helping Past episodes:
6 similar episodes in the past, 1st was 6-8 months ago
Last 12-24 hours This episode more severe than previous
No fevers, rash, weight gain/loss, urinary symptoms,gross
hematuria, recent illness, travel or exposures
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MJ, 4 yo boy
PMH: Previously healthy. No hospitalizations or
chronicillnesses
Meds: none
Allergies: NKDA
Immunizations: UTD
Development: normal
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MJ, 4 yo boy
FH: No pediatric disease. Has 3 healthy siblings, one has
agenesis of one kidney
SH: Lives in Salt Lake City with his parents and siblings
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MJ, 4 yo boy
Physical Exam VS: T 36.1, HR 80, RR 20, BP 123/57, Sat: >90%
on RA
Gen: Awake, alert, in moms arms, crying, clearly in pain HEENT:
Atraumatic, PERRL, conjunctiva clear, TMs normal,
oropharynx clear without erythema or lesions
Neck: Non-tender, no lymphadenopathy
Resp: Clear bilaterally, normal work of breathing
Heart: RRR, normal S1, S2, no murmur, 2+ peripheral pulses Abd:
Tender diffusely, guarding throughout, palpable mass in mid
abdomen, R of midline, no HSM
GU: Circumcised penis, testes down bilaterally, no hernia
Neuro: Grossly normal
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Differential Diagnosis
Oncology/neoplastic Wilms tumor Neuroblastoma Rhabdomyosarcoma
Lymphoma Cystic lymphangioma of
mesentery GU
UPJ obstruction
Nephrolithiasis Hydronephrosis GYN
Ovarian cyst (McCune-Albright)
GI Intussusception
Constipation
ID Abscess
Viral lymphadenopathy
Trauma Hematoma
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Labs
CBC: WBC 21.1 (PMN 79%, lymph 13%, monos 7%),Hgb 14.1, Hct 40.1,
Plts 351
CMP: normal except creatinine 0.61, BUN 20
Lipase: 44, amylase: 73
U/A: WBC 0, RBC 0, bacteria neg, ketones 2+, nitrite,hgb, leuk
esterase, protein all neg
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Imaging
KUB
Non-obstructive, moderate stool in RLQ, no calculi
Abdominal U/S
R renal pelvis distended with mild parenchymal thinning
R ureter not dilated Moderate-to-severe R hydronephrosis,
consistent with
ureteropelvic junction obstruction
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Ureteropelvic junctionobstruction
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Ureteropelvic junctionobstruction
Found in 1:500 antenatal U/S
Most common anatomical cause of antenatal
hydronephrosis
Only about 1/3 cases require intervention
Boys more commonly affected (3-4:1)
More common on L side
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Dietl Syndrome/Crisis
Abdominal pain, nausea, vomiting +/- fever
Tender abdominal mass
Last 1-2 days, recur every 1-2 months
Present similarly to appendicitis, gall bladder disease,
nephrolithiasis Classically, associated with aberrant lower pole
renal
artery
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Dietl Syndrome/Crisis
Exacerbating factors:
Diuresis due to caffeine or alcohol
Trauma
Nephrolithiasis
