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…