The Case: 3 year old girl with constipation and hematuria after abdominal trauma, found to have large abdominal mass with anemia on work up.

Discussion: The challenges in this case included both the medical workup of an constipation (with a possibly related history of hematuria) as well as limitations of working at a satellite site with limited access to certain labs and imaging. Given the chief complaint of constipation, most trainees and attending would start with an X-ray and use the results to inform additional work up. With an X-ray concerning for an abdominal mass, the need for additional lab, imaging, and possible sub-specialist consult and transfer arise. The time in care at which to transfer the patient was a point for discussion, as Dr. Kou pointed out that with compensated shock after trauma, tachycardia, and anemia, it would be important to consider transfusion prior to transfer, even without a definitive diagnosis.

In order to facilitate diagnosis, Dr. Cohen pointed out that this case is ideal for a POCUS study of the abdomen to better characterize this mass. Dr. Agrawal pointed out that gross hematuria in the setting on trauma warrants a work up as it can be a presentation of a renal mass. Many faculty and fellows thought that the history of hematuria two weeks prior after being kicked in the abdomen was a red herring . While the time course makes it challenging in this case, major teaching points are that in patient with hematuria 1. asking about trauma history and 2. consider renal tumors on the differential is important.

Denouement: The patient’s CT findings were compatible on appearance with a Wilms tumor per radiology. She underwent a tumor resection of the Wilms tumor and a left nephrectomy. She was monitored closely in the PICU following her operation with close following by Oncology.

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