Case on Pediatrics : Part 1& 2 Solutions

Case on Pediatrics

Case Study #1 (Part 1):

Mr. and Mrs. B arrive at in the urgent care clinic with their 6 week old infant, S.B. As the practitioner, you ask the couple why they have brought SB to the clinic. Mrs. B states \”My baby breastfed well for the first couple of weeks but has recently been throwing up all the time, sometimes a lot and really forcefully. He looks skinny and is hungry and fussy all the time.\” You determine the couple is homeless and has been living out of their car for the past month. S.B. has had no primary care since discharge after delivery. 

1. What additional information will you need to obtain from Mr. and Mrs. B.?
2. What assessments would you need to do for S.B. based on the information that you have so far?

\”Your primary assessment of the infant reveals the following: S.B. is alert and fussy and consoles with a bottle of Pedialyte (per orders). His anterior fontanel is slighlty depressed and posterior fontanel cannot be palpated. You auscultate regular breath sounds at a rate of 18 breaths per minute. No adventitious sounds. Pulse ox is 98% on room air.

Heart rate is 140 beats per minute with regular rate and rhythm. Brachial and pedal pulses are 3+ and equal. Abdomen is round and nontender to palpation. Positive bowel sounds in all 4 quadrants. Diaper is dry. S.B. moves all extremities and there are no rashes noted. Rectal temperature is 98.9. There is a quarter-sized flat red area on the occiput that \”has been there since he was born\” according to the mother. Slight \”tenting\” was noted.

When interviewing the mother she states that S.B. has only been drinking breastmilk, and will vomit very soon, if not immediately after feeding. She describes the vomiting as projectile, and says that the baby is hungry again after vomiting. 

You transport S.B. to radiology and he vomits a large amount of clear fluid. Patient returns to the room in his mother\’s arms, awake and alert. The mother appears anxious and states, \”I don\’t know what\’s wrong with my baby! Why can\’t you people tell me anything?\”

1. Your institution uses electronic charting. Based on the assessment described, which of the systems would you chart as abnormal as you document your findings? List the abnormal system, along with the abnormal findings.
2. With this new information, what might you add to your assessment and interview questions that you listed last week?
3. What labs would you order for S.B.? Why?
4. What are some differential diagnoses that you are already considering for S.B.

Now I\’m going to add a few things: you have ordered a CBC, CMP, UA, blood pH, and x-rays. You have stated that you are concerned with hydration status and pyloric stenosis. So, here are your questions for the remainder of your case study: 

1. Metabolic alkalosis is a concern for this patient. Which lab findings would you expect with metabolic alkalosis? a. Na: 128 mEq/L, K: 2.6 mEq/L, Cl: 90mEq/L, HCO3: 28 mEq/Lb. Na: 130 mEq/L, K: 5.7 mEq/L, Cl: 94mEq/L, HCO3: 22 mEq/Lc. Na: 130 mEq/L, K: 3.9 mEq/L, Cl: 98 mEq/L, HCO3: 17 mEq/Ld. Na: 148 mEq/L, K: 4.1 mEq/L, Cl: 108 mEq/L, HCO3: 13 mEq/L2.

What is the underlying cause of S.B.’s diagnosis of metabolic alkalosis?

3. Which of these clinical manifestations might you find with metabolic alkalosis? Select all that apply. a. Increased respiratory rate b. Tetanyc. Increased risk for seizures d. Hyperthermiae. Neuromuscular irritability

4. What additional assessment findings might reflect the consequences of prolonged vomiting in the infant?

5. The abdominal x-ray reveals a distended stomach with minimal distal intestinal bowel gas. You decide to order an ultrasound, which reveals a thickened pyloric muscle. What is your final diagnosis, as well as 5 other differential diagnoses?

6. You admit S.B. to the pediatric unit with a surgical consult. What are some socioeconomic/familial concerns that you may have in regard to his hospitalization, procedure, recovery, and overall health?

*** Remember to include in-text citations for any references, along with a title page and reference page. Question and answer format is acceptable, however APA is still expected.

Solution

Case on Pediatrics

1. What additional information will you need to obtain from Mr. and Mrs. B.?

Some of the additional information I would obtain from Mr. and Mrs. B include her pregnancy, child’s birth information, Mrs. B’s diet, if there is anything else fed to the child, and any other symptoms presented by the infant. While poor living conditions are the most probable cause of the child’s gastrointestinal disorders, this information may help identify if there are other factors contributing to this problem.

• What assessments would you need to do for S.B. based on your information so far?

S.B needs a physical and medical history assessment to help assess the problem to get the right diagnosis. This includes vital signs such as temperature, weight, height, BMI, and examining the child’s physical appearance, including skin and abdomen.

1. Your institution uses electronic charting. Based on the assessment described, which of the systems would you chart as abnormal as you document your findings? List the abnormal system, along with the abnormal findings.

The abnormal findings include slightly depressed anterior fontanel and 18 breaths per minute, indicating an issue with the skeletal and respiratory systems related to malnutrition and dehydration.

2. With this new information, what might you add to your assessment and interview questions that you listed last week?

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I would add lab tests to the assessment to build on the diagnosis.

3. What labs would you order for S.B.? Why?

I would order blood tests to show the levels of specific substances in the blood. Specifically, it would provide information on hydration, possible infection, electrolyte imbalance, and kidney function (Raucci et al., 2020).

4. What are some differential diagnoses that you are already considering for S.B?

The differential diagnoses in consideration include pyloric stenosis and gastroenteritis. Pyloric stenosis is a gastrointestinal problem that causes infants to vomit often and forcefully. It may lead to dehydration and malnutrition, which requires immediate care. Nonetheless, gastroenteritis is also common in young children and is associated with vomiting and frequent watery bowel motions.

1. Metabolic alkalosis is a concern for this patient. Which lab findings would you expect with metabolic alkalosis?

Na: 128 mEq/L, K: 2.6 mEq/L, Cl: 90mEq/L, HCO3: 28 mEq/Lb

• What is the underlying cause of S.B.’s diagnosis of metabolic alkalosis?

The underlying cause of S.B.’s metabolic alkalosis diagnosis is the loss of gastric secretions leading to dehydration.

• Which of these clinical manifestations might you find with metabolic alkalosis?

The most common clinical manifestation of metabolic alkalosis is tetany because some proteins, such as albumin, are highly ionized into anions as the blood P.H. increases. As a result, free calcium in the blood strongly binds with albumin causing tetany. Additionally, the infant is at risk of seizures and neuromuscular irritability due to low sodium levels.

• What additional assessment findings might reflect the consequences of prolonged vomiting in the infant?

The assessment findings reflecting prolonged vomiting include severe dehydration, weight loss, metabolic abnormalities, jaundice, and growth and development abnormalities.

• The abdominal x-ray reveals a distended stomach with minimal distal intestinal bowel gas. You decide to order an ultrasound, which reveals a thickened pyloric muscle. What is your final diagnosis, as well as five other differential diagnoses?

The final diagnosis is infantile hypertrophic pyloric stenosis. This condition is caused by hypertrophy of the pylorus, which progresses to near-complete gastric outlet obstruction, leading to forceful vomiting (Galea & Said, 2018). Other differential diagnoses include gastroenteritis, metabolic alkalosis, dehydration, gastric reflux, and inborn errors of metabolism.

• You admit S.B. to the pediatric unit with a surgical consult. What are some socio-economic/familial concerns you may have regarding his hospitalization, procedure, recovery, and overall health?

One of the main socio-economic concerns I have for S.B. and his family is housing. The parents report that they have been homeless and living out of their care for the past month. According to Clark et al. (2019), infants exposed to homelessness are prone to have low weights, frequent readmissions, and adverse health conditions. Therefore, there is a need to provide the family with housing solutions to improve their quality of life. Some of the alternatives I would consider are emergency homeless shelters and staying at a friend’s or relative’s place temporarily until they are stable enough to get home.

Homeless shelters may be ideal for the family as they provide necessities, food, and education, and the parents may find employment opportunities. However, living with relatives or friends is an ideal environment for the child to promote his health outcomes. Nonetheless, I would educate the parents on the need to adhere to medication, take proper diets, and follow up on the clinics. I would also educate the parents on the alarming signs they should look for in the child to seek medical attention.

References

Clark, R. E., Weinreb, L., Flahive, J. M., & Seifert, R. W. (2019). Infants exposed to homelessness: Health, health care use, and health spending from birth to age six. Health Affairs, 38(5), 721-728. https://doi.org/10.1377/hlthaff.2019.00090

Galea, R., & Said, E. (2018). Infantile hypertrophic pyloric stenosis: An epidemiological review. Neonatal Network, 37(4), 197-204. https://doi.org/10.1891/0730-0832.37.4.197

Raucci, U., Borrelli, O., Di Nardo, G., Tambucci, R., Pavone, P., Salvatore, S., Baldassarre, M. E., Cordelli, D. M., Falsaperla, R., Felici, E., Ferilli, M. A., Grosso, S., Mallardo, S., Martinelli, D., Quitadamo, P., Pensabene, L., Romano, C., Savasta, S., Spalice, A., … Parisi, P. (2020). Cyclic vomiting syndrome in children. Frontiers in Neurology, 11. https://doi.org/10.3389/fneur.2020.583425

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