A mother presents her 16-month-old son to his PCP for an evaluation of irritability and crying for the past 5 hours
Chief Complaint
“Irritable and crying toddler.”
History of Present Illness
A mother presents her 16-month-old son to his PCP for an evaluation of irritability and crying for the past 5 hours. According to his mother, the child was fine when he suddenly became fussy and appeared to be in pain. He has no nausea, vomiting, diarrhea, fever, cough, or cold symptoms. His mother was alarmed by the sudden off-on episodes of crying. She explains that when he has short bursts of excruciating pain, he doubles over, or if he is being held, his legs have to pull up to his chest. The child seems to be fine in between these episodes. Typically, the child is calm.
Review of Systems
The patient’s ROS is positive for irritability and possibly abdominal pain. His ROS is negative for nausea, vomiting, bloody stool, constipation, fever, chills, and cough.
Relevant history
The child was a normal spontaneous vaginal delivery at term without any complications. He has continued to thrive, hitting all developmental milestones. He has not been hospitalized, nor is he on any chronic medications.
Allergies
No known drug allergies; no known food allergies.
Medications
None.
Physical Examination
Vitals: T 37.0°C (98.6°F), P 120, R 28, BP 100/65, WT 9.9 kg (22 lbs) 10th percentile, HT 76.2 cm (30 in.) 5th percentile, BMI 16.5.
General: Alert and engaging when not having an episode of pain. He is non-toxic looking.
Psychiatric: Irritable.
Skin, Hair, and Nails: Pink with a 1–2-second capillary refill. No abnormal findings with hair or nails.
Head: No signs of trauma.
Eyes: PERRL.
ENT/Mouth: Moist oral mucosa with no signs of dehydration.
Neck: FROM with no nuchal rigidity.
Lungs: Clear to auscultation bilaterally, equal breath sounds.
Heart: RRR, no murmurs.
Abdomen: Soft and non-distended. Mild tenderness with fullness in the right upper abdomen. The right lower abdomen is scaphoid and feels “empty” on palpation (Dance sign).
Genital/Rectal: Genital exam without abnormal finding; stool is hemoccult negative.
Neurologic: Alert and not lethargic.
Clinical Discussion Questions
Give three (3) differential diagnoses. (Explain how you ruled in and ruled out each differential diagnosis.)
What is the most likely diagnosis? (Explain how you arrived at your diagnosis)
Demonstrate your understanding of the pathophysiology in regard to the most likely diagnosis.
What are the next appropriate steps in management? (Management should be confined to an outpatient setting, this includes proper referral if needed)
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