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Final clinical long case 5

Created: 7/4/2004

You are presented with a 7 year old male child with acute painful swelling in the left scrotum, vomiting and torsion of the testes. He has had a cough and been wheezing for 3 days. He had his last meal 4 hours ago. He has been asthmatic for the past 3 years and is currently taking salbutamol and beclomethasone inhalers.

On examination:

The child is found to be very anxious and in pain. He is mildly dehydrated, and weighs 19 kg.

Respiratory signs

– Respiratory rate: 28/min
– Left lower zone: air entry decreased
– Percussion note decreased
– Bilateral rhonchi
– Abdominal examination: scrotum – nothing abnormal detected

Cardiovascular signs

– Heart rate: >120 bpm
– Blood pressure: 110/60 mmHg
– Auscultation: nothing abnormal detected

The result of investigations are as follows:

– Haemoglobin: 10.6 g/dl
– White blood cell count: 14,600/ml
– Neutrophil count: 80 x 106 ml (Normal range 2-7) 
– lymphocyte count: 20 x 106 ml (Normal range 1.5-4)
– Packed cell volume: 40%

Other investigations carried out:

– Chest X-Ray
– Urea and electrolytes
– Na+
– K+
– Creatinine

QUESTIONS (answers below)

1. Summarise the patient and identify the problems associated with this case.
2 Give the differential diagnosis.
3. Discuss childhood asthma.
4. How do you assess severity of asthma?
5. Comment on investigations.
6. How would you manage this child?
7. How would you anaesthetise this child?


1.  Emergency surgery - risk of ischaemia
Lower respiratory tract infection
Full stomach
Pain relief

2.  Infection - epididymo-orchitis, abscess
Trauma – haematoma
Obstructed hernia

3.  Disappears after about 10–15 years
10–15% progress to have adult asthma
Family history of atopy

4.  Patient’s history:
Off school/work - frequency
Hospital admissions/ITU admissions
Steroid courses given

On examination:

Heart rate: pulsus paradox
Silent chest
Cyanosis - very late
PEFR <30% predicted

5.  White blood cell count increase:  could be due to epididymo-orchitis or urinary tract infection
Haemoglobin decrease: could be due to malnutrition
Is the child dehydrated?
Weight: expected weight 22 kg [(age x 2) + 8 kg]. Why has his weight decreased?

6. The following areas should be covered:
Fluids - maintenance and allowance for dehydration, signs of adequate hydration
Optimise bronchodilators
Treat infection; steroid cover

7.  Premedication
EMLA/AMHOP (Eutectic mixture of LA)
General anaesthesia
Rapid sequence induction: as the child has a full stomach, suxamethonium? rocuronium
Endotracheal tube size: diameter - [Age/4] + 4.5 ; length - [Age/2] + 12
Intra-operative analgesia
Non-steroidal anti-inflammatory drugs
Caudal anaesthesia - dose

Postoperative care
Pain relief

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