An 11-month-old girl is brought to the emergency department by her stepfather because she is "not acting like herself." For the past 2 days, the girl has had intermittent episodes, lasting 10-15 minutes, during which she cries inconsolably and flexes her hips. Since this morning, the patient has seemed more tired, napping more than usual. Her appetite has been poor; she did not eat breakfast today. The girl was born at term and has no chronic medical conditions. Temperature is 36.7 C (98 F), blood pressure is 100/62 mm Hg, pulse is 160/min, and respirations are 20/min. On examination, the patient is alert but appears tired. Anterior fontanelle is closed. Oral mucous membranes are slightly dry, and the neck is supple. Cardiopulmonary examination is unremarkable. The abdomen is mildly tender but nondistended. There is no rebound tenderness or guarding. Neurologic examination shows equal and reactive pupils, and the face appears symmetric. Strength is 5/5 bilaterally, and reflexes are equal. Which of the following is the best next step in management of this patient?

Question

An 11-month-old girl is brought to the emergency department by her stepfather because she is "not acting like herself."  For the past 2 days, the girl has had intermittent episodes, lasting 10-15 minutes, during which she cries inconsolably and flexes her hips.  Since this morning, the patient has seemed more tired, napping more than usual.  Her appetite has been poor; she did not eat breakfast today.  The girl was born at term and has no chronic medical conditions.  Temperature is 36.7 C (98 F), blood pressure is 100/62 mm Hg, pulse is 160/min, and respirations are 20/min.  On examination, the patient is alert but appears tired.  Anterior fontanelle is closed.  Oral mucous membranes are slightly dry, and the neck is supple.  Cardiopulmonary examination is unremarkable.  The abdomen is mildly tender but nondistended.  There is no rebound tenderness or guarding.  Neurologic examination shows equal and reactive pupils, and the face appears symmetric.  Strength is 5/5 bilaterally, and reflexes are equal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5e5_8b39_bc81_c556a1cea6fb_MD0003_00 Episodic crying, abdominal tenderness, and lethargy suggest intussusception, an intestinal emergency most common in children age 6-36 months. Intussusception occurs when a segment of bowel telescopes into an adjacent segment. Intermittent contraction of the telescoped bowel during peristalsis results in the classic presentation of episodic inconsolable crying with legs flexed and drawn into the abdomen, followed by asymptomatic periods of normal activity. Increasing lethargy occurs with progressive episodes and, in a minority of cases, may be the presenting sign (particularly in infants). bowel telescopes Early detection is critical to avoid bowel obstruction and ischemia of the involved segment (ie, bloody currant jelly stool). Examination may reveal abdominal tenderness or a sausage-shaped abdominal mass but is often normal. The first step in management of suspected intussusception is abdominal ultrasound, which reveals the telescoped intestine as a target sign, or two concentric circles. Abdominal x-ray may also be performed to exclude intestinal perforation that would warrant surgical management. target sign Air (or saline) enema is the treatment of choice to reduce intussusception nonsurgically. (Choice B) Blood and urine cultures may be ordered for abdominal pain and poor appetite suggestive of sepsis (eg, due to urinary tract infection). However, infection is unlikely without fever, and this patient's intermittent symptoms make intussusception more likely. (Choice C) CT scan of the head may be indicated in patients with signs of increased intracranial pressure (ICP). Although this patient appears tired, she is alert with no hypertension, bradycardia, or focal neurologic deficits to suggest increased ICP. (Choice D) Lumbar puncture is used to test for meningitis, which may be suspected in a patient with lethargy, fever, and neck stiffness. In contrast, this patient is afebrile with intermittent symptoms and a normal neurologic examination. (Choice E) Screening for an accidental ingestion (eg, benzodiazepine) includes urine drug testing and may be considered in a young child with atypical behavior or lethargy. However, persistent (not episodic) symptoms would be expected. (Choice F) Urine organic acid panel is used to test for organic acidemias, which are inborn errors of metabolism that typically present in the first few weeks of life with vomiting, lethargy, seizures, and failure to thrive. Educational objective: Intussusception is an abdominal emergency. Affected patients have episodes of inconsolable crying, with legs drawn to the abdomen due to pain, followed by asymptomatic periods. Abdominal ultrasound is diagnostic and reveals a target sign, which represents a bowel segment telescoping into another. References: Intussusception: past, present, and future. (http://www.ncbi.nlm.nih.gov/pubmed/28779197)

An 11-Month-Old Girl Is Brought to the Emergency Department by Her