Case 1 - Miguel

• You are a clinician working in an emergency department in Queensland.
• You are about see a 4 year old male called Miguel who was brought in by his father Antonio. Antonio tells you the reason they presented was that Miguel has not passed a stool in 6 days.
• Observations: RR: 18   O2: 99%   T: 36.4   HR: 90
• The history is notable for 6 days of not passing stools. He has a long-standing history of constipation. He generally passes bowel motions every 2 to 4 days. He occasionally takes 1 sachet of Movicol if he has not passed a motion for a few days.
• There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Miguel appears well and is interactive. He has a soft abdomen with mild distension, with non-specific mild tenderness in the lower abdomen. The rest of the examination, including a neurological examination, is normal. He is not clinically dehydrated.

Questions to discuss about Miguel’s case

• What is required to diagnose constipation?
• What are some underlying abnormalities to consider that can cause constipation?
  • What is the likelihood that constipation is related to an underlying abnormality (e.g. hypothyroidism) versus it being a functional faecal retention (no underlying abnormality)?
  • What are some red flags that may suggest an underlying pathology for Miguel’s constipation?
• What investigations (if any) would you request for Miguel?
• How would you manage Miguel (assuming no red flags on your assessment)?

Normal range for vital signs by age

Case 2 - Abdel

• You are a clinician working in an emergency department in Queensland.
• You are about see a 2 year old male called Abdel who was brought in by his father Rashed. Rashed tells you the reason they presented was that Abdel has had 2 days of persistent vomiting and diarrhoea with poor oral intake.
• Observations: RR: 25   O2: 99%   T: 37.4   HR: 165   BP: 100/60 (MAP 73)
• There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Abdel appears well, but is quiet. Your assessment of dehydration identifies that Abdel is clinically dehydrated but not shocked. He has a reassuring abdominal, respiratory and cardiovascular examinations.

Questions to discuss about Abdel’s case

• What aspects of the examination are helpful in assessing for dehydration in Abdel?
• What would make you consider a child as being at higher risk for dehydration?
• What are some differential diagnoses to consider in Abdel?
  • What are some red flags that would suggest an alternative diagnosis?
• What tests (if any) would you perform for Abdel?
• How would you manage Abdel if:
  • He was shocked?
  • He was clinically dehydrated (and not shocked)?
  • He was not clinically dehydrated?

Normal range for vital signs by age

Case 3 - Rachel

• You are a clinician working in an emergency department in Queensland.
• You are about see a 2 year old female called Rachel who was brought in by her mother Rebecca. Rebecca tells you the reason they presented was that Rachel has had a 2 week history of increased thirst, increased hunger, and has been passing urine more frequently. She has also been complaining of abdominal pain.
• Observations: RR: 25   O2: 99%   T: 37.4   HR: 130   BP: 100/60 (MAP 73)
• Rebecca has celiac disease. There is no other relevant family history. There were no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, and social history.
• On examination, Rachel appears well, but is slightly lethargic. She has a reassuring abdominal, respiratory and cardiovascular examinations.
• The BSL machine reads as 18. The ketones are 4.

Questions to discuss about Rachel’s case

• What is the most likely diagnosis?
  • What is required before you can diagnose DKA in Rachel?
  • How would you assess hydration in Rachel?
  • What are some triggers of DKA in a child with known type 1 diabetes mellitus?
• What investigations would you request?
• How would you initially manage Rachel if she had the following conditions? Consider the aims of treatment in DKA as part of your discussion.
  • Mild DKA.
  • Moderate to severe DKA.
• What are the risk factors, symptoms/signs of, and management of cerebral oedema in a child with DKA?

Normal range for vital signs by age

Case 4 - Johnny

• You are a clinician working in an emergency department in Queensland.
• You are about see a 4 week old male called Johnny who was brought in by his mother Jennifer and father Robert. Their concern is Johnny’s vomiting. Johnny has been vomiting for the past 12 to 24 hours. On further questioning, the vomiting is described as non-bilious and projectile. It is after each feed. He seems more lethargic compared to usual. He has always been a child who has small vomits but they note that these vomits are different. There is no history of fevers or other infective symptoms.
• Observations: RR: 45   O2: 99%   T: 36.4   HR: 140   BP: 85/46 (MAP 59)
• There are no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Johnny appears lethargic but not toxic. There is no evidence of clinical dehydration. He has a normal cardiovascular, respiratory, and abdominal examination. During your examination, he has a projectile vomit and is noted to be unsettled and seeking a further feed.

Questions to discuss about Johnny’s case

• What is the most likely diagnosis?
  • Discuss the age range expected and risk factors.
• What are some differential diagnoses?
• What investigations should you consider?
  • Discuss the acid/base abnormality you may see.
• How would you manage Johnny?

Normal range for vital signs by age

Case 5 - Tina

• You are a clinician working in an emergency department in Queensland.
• You are about see a 9 month old female called Tina who was brought in by her mothers Annette and Francesca. Their main concern is unsettled behaviour for the past 4 hours. Tina has been having intermittent episodes of pain. During these episodes, she is extremely unsettled and appeared pale for approximately 10 to 15 minutes, and then proceeds to 'go back to normal'. Initially they thought she may be 'over tired' but have become concerned with time. There has not been any vomiting, changes to stool, fevers, or other infective symptoms.
• Observations: RR: 35   O2: 99%   T: 36.4   HR: 135   BP: 85/55 (MAP 65)
• There are no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Tina appears well. She is not clinically dehydrated. She has a normal cardiovascular, respiratory, and abdominal examination.

Questions to discuss about Tina’s case

• What is the most likely diagnosis?
  • Discuss the age range, Hx, Ex, classic triad (how commonly seen), risk factors.
• How would you investigate Tina?
• How would you manage Tina?

Normal range for vital signs by age

Case 6 - Luisa

• You are a clinician working in an emergency department in Queensland.
• You are about see a 14 year old female called Luisa who was brought in by her father Jake.
• Their main concern is abdominal pain. This started with periumbilical abdominal pain the day prior. It is now in the RLQ and is 7/10 in severity. Luisa has vomited twice. Her appetite is poor. She has felt warm but has not measured the temperature with a thermometer. There is no history of preceding coryzal symptoms. She has no rhinorrhea, cough, urinary symptoms, or sick contacts. You also take a menstrual history, and a focused HEAADSSS assessment.
• Observations: RR: 21   O2: 99%   T: 38.9   HR: 120   BP: 110/70 (MAP 83)
• There are no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Luisa appears uncomfortable but not toxic. Abdominal examination reveals pain in RIF with no evidence of peritonism. She has rebound tenderness, is McBurney’s positive, and Rovsing’s negative. Her cardiovascular and respiratory examinations are normal. She is not clinically dehydrated.

Questions to discuss about Luisa’s case

• What is the most likely diagnosis?
• What is your differential diagnosis?
• How would you investigate Luisa?
• How would you manage Luisa?

Normal range for vital signs by age

Case 7 - Rahul

• You are a clinician working in an emergency department in Queensland.
• You are about see a 13 year old male called Rahul who was brought in by his mother Apoorva. Their main concern is testicular pain. This has been ongoing for 1 hour and is described as 9/10. The pain came on suddenly. He has not had analgesia.
• Observations: RR: 18   O2: 99%   T: 36.5   HR: 120   BP: 110/70 (MAP 83)
• There are no relevant or concerning findings on perinatal history, developmental history, medical history, medications, allergies, vaccinations, family history, and social history.
• On examination, Rahul appears very uncomfortable. You examine his testes with consent with an appropriate chaperone in place. His testes appear swollen. It is difficult to discern which teste is more swollen. The right teste appears to be high riding. The right teste is tender to palpation. The cremasteric reflex on the right is absent. There is some pain in the RIF. His respiratory, and cardiovascular examinations are normal.

Questions to discuss about Rahul’s case

• What is the most likely diagnosis?
• What is the role for ultrasound in the acute setting?
• What is your management?
  • Discuss the specific referral pathway in your hospital.

Normal range for vital signs by age