RD7.5 | Imaging in Paediatrics — Assignment

CLINICAL SCENARIO

You are the paediatric resident on call. A 22-month-old girl is brought to the emergency department with 3 days of fever, cough and fast breathing. Two weeks earlier she had completed treatment for a febrile urinary tract infection. On examination she is alert but tachypnoeic (respiratory rate 48/min), SpO2 94% on room air, with reduced breath sounds and dullness to percussion at the right base. Her mother also recalls that around the time the cough began, the child had a brief choking episode while eating roasted chickpeas, after which she coughed for a few minutes and then settled. The consultant asks you to integrate appropriate paediatric imaging into this child's management — choosing wisely under the 'image gently' / ALARA principle.

Explain why this child, as a 22-month-old, warrants extra caution with ionising radiation. Briefly outline the 'image gently' / ALARA principle and how it sets your default preference for ultrasound and MRI over CT and even over unnecessary radiographs. State your overall imaging philosophy for this multi-problem child before ordering anything.

This child has features that could represent a complicated chest infection AND a possible foreign body aspiration. Decide your first imaging step for the chest and justify it. Address: (a) whether the chest signs (dullness, reduced breath sounds) warrant imaging and which modality best assesses possible pleural fluid; (b) how the choking history changes your interpretation; and (c) why a normal chest radiograph would NOT exclude an aspirated radiolucent foreign body. State what additional radiographic views could unmask air-trapping and what indirect signs you would look for.

Construct two short branches. Branch A: the chest ultrasound shows a septated right pleural effusion — describe how this changes management. Branch B: the chest radiograph is normal but the choking history remains convincing — describe how this changes management, and explicitly state the role of bronchoscopy (diagnostic AND therapeutic). Make clear in each branch how the imaging finding (or its absence) drives the next clinical step.

Given the recent febrile UTI, decide what uroradiological work-up (if any) is appropriate and justify it using age- and risk-based (NICE/ISPN) protocols. Map the three tools to their single questions: ultrasound (anatomy), MCUG/VCUG (reflux, graded I-V), DMSA (cortical scarring/pyelonephritis). State which you would order for this child and why, and how an abnormal result in each would change long-term management (e.g., prophylaxis, surgical referral, follow-up).

Bring it together into a single prioritised plan. List, in order, the imaging you would actually request for this child, the question each test answers, and the management decision each result would inform. Conclude with one sentence on how you minimised cumulative radiation while still answering every clinical question.