GERD CASE MANAGEMENT

PRESENTATION

BY

DR EFFIOM, VICTOR E.

HO

Pediatrics

BIODATA

C.C.G

3 Months

Male

No. 4 Asari Iso Layout Street, Calabar.

Hails from Imo state, Igbo Tribe.

Christian

Admission: Via CHER

Informant: Mother (Reliable)

History

PC:

-Vomiting since birth

-Swelling on the left Forearm x 1/52

-Fever x 4/7

-Passage of watery stools X 3/7

-Cough and catarrh x 1/7

History Of Presenting Complaint (A).

Vomiting was noted since 1st day of life.

Non-projectile, non-forceful, persistent, post-prandial, non-bilious, usually from immediately after meals to 30 mins. post feeding.

Quantity depended on quantity of breast milk intake. There was no associated history of loss of appetite as child was always eager to suckle at breast.

Color is that of breast milk, not blood stained and not offensive.

Episodes of vomiting mostly averaged 10x per day. Had vomited 6x already prior to presentation at CHER.

Nil abdominal swelling.

HISTORY OF PRESENTING COMPLAINT

Swelling on left forearm was initially small in size measuring

about the size of a peanut.

Swelling had progressively enlarged but did not discharge any

purulent effluents.

No differential warmth. Mild tenderness. Not fixed to underlying

tissue.

No preceding trauma or injury

Fever started 4/7 prior to presentation at

CHER.

Was high-grade and continuous.

Nil convulsions, nil excessive crying or crying

during micturition

Nil tugging of the ears

Subsides with administration of tabs PCM and

tepid sponging.

HISTORY OF PRESENTING COMPLAINT

CONTD. Passage of watery stools noticed 3/7 days prior

to presentation

Sudden onset

Occurred on an average almost 8x in a day

Non-mucoid, not blood stained, non-copious.

no curling up or crying to show abdominal pain

Cough: Non-paroxysmal.

Nil difficulty in breathing, nil fast breathing,

Had no variation with time of the day (Not worse at night)

Occasionally associated with post prandial vomiting.

Nil hx. of force feeding

No known aggravating or relieving factors.

no bluish discoloration of lips and extremities.

For the above set of complaints, baby and mother

presented at the CHER for expert management.

PAST MEDICAL HX.

Baby was admitted during neonatal period on account

of jaundice and was treated with phototherapy.

Prenatal, Natal and Post Natal History.

Spontaneous conception & desired

Received 2 doses of TT & IPTp.

Was placed on Haematinics and vitamin C through out

duration of pregnancy.

Investigations done for RVS, HBsAg, HCV were all

negative.

Not a known HEADS0

Delivery via Elective Caesarean section

Outcome live male Neonate, Wt: 3.2kg.

Baby cried immediately after birth

Exclusive breastfeeding/immunised for age.

Puerperium was uneventful.

DIETARY AND NUTRITIONAL

HISTORY.

Predominant breastfeeding x 2months

Currently supplementing by adding guinea corn, millet

and NAN 3x daily. Recently introduced another milk

2/52 with no improvement.

Immunization Hx.

Has been immunized for age

Developmental History:

- No Neck control, sustained grasp of objects.

FAMILY AND SOCIAL HISTORY

• Patient is third in a family of 3, (2 males and 1

female, all alive and well).

• Both parents are alive and well.

• Mother is a 23 year old graduate, unemployed.

• Father is a ? old plumber, self employed with

secondary level of education.

SUMMARY

I have presented the case of C.C.G a 3 months old infant

who presented at the Children emergency clinic with

complaints of Vomiting since birth, Swelling on the left

Forearm x 1/52, Fever x 4/7, Passage of watery stools X 3/7

and Cough and catarrh x 1/7.

PHYSICAL EXAMINATION

o A conscious, Small for age, afebrile (36.70C), not pale,

anicteric, acyanosed, not dehydrated, not in respiratory

distress, no peripheral Lymphadenopathy, nil pedal edema,

no dysmorphic features.

o Anthropometry

*OFC: 39cm (Adequate)

*Weight: 3.6kg (~60th pecentile)

*Length: 54cm (75th percentile)

.

oABD: full, moved with respiration, soft.

Liver was palpated about 2cm below the costal

margin, firm, smooth and non-tender.

RESPIRATORY SYSTEM

o RR – 44 cpm,

o Vesicular breath sounds, nil crepitations.

CARDIOVASCULAR SYSTEM

o PR - 140 b.p.m, regular, normal volume.

o BP – no appropriate cuff.

o heart sounds: S1, S2 only. No murmurs

MSS: Mass on left forearm measuring 2.5cm by 2cm. Firm, no

differential warmth.

CNS: Conscious and alert, AF: flat and normotensive, no

neck control, nil signs of meningeal irritation, normal tone in

all limbs.

Working Diagnosis (CHER) 1. Partial Intestinal obstruction ? Cause r/o Congenital

hypertrophic pyloric Stenosis

2. Sepsis (furunculosis, diarrheal disease + URTI)

Treatment

①Admitted to CHER.

②Carry out following investigations; MP,

Abdominal USS, FBC, Barium meal and follow

through, E,U,Cr.

ORS Plan A 50-100/mls per loose stool.

Started on IV Ampiclox 180mg every 6hrs till reviewed

Tabs Zinc 10mg daily x 2/52

Vitamin A 100,000IU dly x 2days, then 1 dose 2weeks

later.

Investigations: Retrieved on 2nd day of admission.

FBC

a. PCV: 42%

b. WBC: 7.8 X 109/L

c. Neutrophils = 28%

d. Eosinophil = 1%

e. Lymphocyte = 71%

f. Monocytes = 0%

MP

Trophozoites of P. Falciparum + seen.

E/U/Cr

1. Urea: 3.0 mmol/l

2. Na+: 137mmol/l

3. K+: 3.6 mmol/l

4. HCO3: 25mmol/l

5. Cl--: 98mmol/l

6. Creatinine: 102umol/l.

On the 4th day of admission, patient was no more passing watery stools. Has had 6 episodes of vomiting over past 24 hours.

Vital signs had been stable since admission and child was sucking well at breast.

Swelling over the anterolateral part of the L. forearm had become fluctuant in consistency.

Plan was initiated to

• Do an Incision and drainage for abscess. Consult was sent to the PSU.

• Introduction of syrup P-Alaxin 7.5mls dly x 3/7 following MP result.

• Continue breastfeeding and present medications (Ampiclox, zinc)

On the 8th day of admission,

ABD USS: no abnormality detected.

Barium swallow meal and follow through: Normal.

Current weight: 3.7kg

::: A diagnosis of Gastroesophageal Reflux Disease

Plan Counseling the mother

Commencement of cereal and infant formula

Put patient to lie prone

Alternate day weighing

Keep feeding/vomitus chart

Small frequent feeds (cereal and infant formula) @

30mls 2hrly x 24hrs and then further reduced to 10mls

hourly.

On the 9th day of admission, regurgitation had reduced

in frequency since the commencement of NAN 1 and

patient is also lying prone.

Weight on day 9 of admission was 3.9kg

Abscess had reduced drastically in size.

Vital signs remained stable.

Was to complete 7 days of IV Ampiclox.

Patient continued to improve clinically.

Vomiting little quantity.

Mother admits to child’s improved clinical state

and requests discharge home.

Weight was 4.05kg

Patient was discharged home on mothers

request.

Continue oral tabs zinc 10mg daily.

Feed 10mls hourly.

Nurse prone and keep upright for 30mins after feeding.

See in clinic in 3/7.

FOLLOW UP VISIT 1. Age: 4 months 5 days.

Weight: 4.5kg

RR: 40cpm

Patient is gaining weight (gained 0.45kg in 3 days)

Tolerating frisco rice with NAN 1

Regurgitation reducing in volume and frequency.

Neck control is improving.

Mother happy with infant’s improvement.

Mother advised to continue small, frequent feeds and keep upright for at least 30mins after feeding. Infant to lie prone.

To see in clinic in 2/52.

Follow up visit 2

Age: 4 months

Wgt was 5kg. (83% of EWA)

OFC=41cm

Length=60cm

Chest is clear.

Doing well.

Vomiting had reduced in frequency and volume.

Had attained neck control.

Nil fresh complaints.

Continue with feeding as prescribed

See in 1/12.

Thank you…