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ROSIMO - AUG 2021 NB Vomiting
ROSIMO - AUG 2021 NB Vomiting
ROSIMO - AUG 2021 NB Vomiting
Rosimo
4MD
GENERAL DATA
M.C. G., male, 3 days old, Filipino, Roman Catholic, delivered in a lying clinic via
NSVD, cephalic presentation , 38 wks AOG , with a birthweight 2,600 gms AGA, APGAR
score of 8,9 , EINC done. Patient was able to passed out stools and urine within 24 hours and
so was discharged after 1 day.
MATERNAL HISTORY:
FIRST TRIMESTER:
The mother experienced the usual signs and symptoms of early pregnancy such as urinary
frequency, breast tenderness, easy fatigability, nausea and vomiting. On the 1st month of
missed period, self-pregnancy test was done, which revealed positive result. On the same
month, she consulted a private physician where the following diagnostic tests such as CBC,
Hepatitis B antigen screening, VDRL/RPR, and fasting blood sugar which revealed normal
results. Ultrasound done revealed a single, live, intrauterine pregnancy compatible to 11
weeks 5 days age of gestation by average crown rump length with good cardiac and somatic
activities. She was given multivitamins 1 tablet per day and folic acid 1 tablet once a day
which she took irregularly. She denies any history of accidents, trauma, illnesses or exposure
to radiation and toxic chemicals.
SECOND TRIMESTER
Quickening was felt on 5th month of pregnancy (November 2019). She had regular prenatal
checkup and regular intake of multivitamins, calcium and Ferrous Sulfate. Complete blood
count, urinalysis, HBsAg, Oral Glucose Tolerance test, fasting blood sugar and urinalysis
were all normal. Other had a history of cough and fever. Her Obstetrician gave her antibiotic
of 7 days duration. She denies any history of accidents, trauma, or any exposure to radiation
or toxic chemicals.
THIRD TRIMESTER
Subsequent prenatal checkup as well as intake multivitamins, calcium and ferrous Sulfate
were regular, Abdominal ultrasound was done few weeks prior to EDC, which revealed a
single, live, intrauterine pregnancy with good cardiac and somatic activities, Fetus in cephalic
presentation, antero-fundal grade 3 placenta. Biophysical score was indicative of good fetal
well-being.
BIRTH OUTCOME:
The patient is a Live, fullterm, single, male, delivered via NSVD, BW of 2,600 grams ,
AGA, APGAR score 8,9 in a Lying -in clinic. Discharge after one day stay without any
problem noted post -natally.
FAMILY HISTORY:
Paternal Grandfather: (+) DM and Hyptension
Elder Sibling (Brother): (+) asthma
SOCIO-ECONOMIC HISTORY:
Father is computer analyst in a private company, while mother is a secretary in a textile
company. The family lives in a rented two room apartment which is near a textile company
where textiles are treated with chemical dye. Garbage collected regularly. Drinking water is
being bought in a water filtering station.
FEEDING HISTORY:
Breastfeeding since birth direct feeding thru the breast then later dropper feeding of stored
breastmilk
IMMUNIZATION:
BCG and Hepatitis B at birth
PHYSICAL EXAMINATION:
General survey: irritable, conscious, pinkish, in respiratory distress
Vital signs: RR: 65 breaths/ min CAR: 130beats/ min
Temp: 36.7 degrees centigrade
Anthropometric measurements:
BW: 2,600 gms Birth length: 49 cm
HC: 34 cm CC: 33 cm
Pertinent findings:
HEENT: Open, flat, soft anterior and posterior fontanels, positive ROR, bilateral, pink
palpebral conjunctiva, white sclera, patent ear canals, with nasal flaring and grunting, moist
lips and moist buccal mucosa
CHEST/LUNGS: Symmetrical chest expansion, with subcostal and intercostal retractions,
course rales on both lung fields
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmur
ABDOMEN: Slightly globular, soft, no mass, no organomegaly, with bowel sounds,
umbilical cord has 2 arteries and 1 vein
SPINE: Straight, midline, no tufts of hair, no mass
GENITALIA: Normal looking male external genitalia, no urine output yet
EXTREMITIES: No gross deformities, full and equal pulses, CRT <2 seconds
SKIN: Cyanotic, prominent visible veins , no active dermatoses
REFLEXES: Positive Babinski, Moro and Rooting Reflexes
GUIDE QUESTIONS:
1. What are the salient features of the case?
- Patient presented with episodes of coughing, cyanosis (specifically in the mouth) and was in
respiratory-distress.
- Feeding exacerbates the symptoms manifested by the patient.
- Course rales on both lung fields upon auscultation.
- Subcostal and intercostal retractions.
- RR of 65 breaths/min
- The case strongly suggests Tracheoesophageal fistula in a live birth, full term infant. This is
so because of the symptoms manifested like vomiting, cyanotic, coughing and in respiratory
distress plus exacerbated by feeding.
5. What are your diagnostic procedures for your patient? Justify for each.
a) Perinatal radiograph: examine for absence of the infant stomach bubble and maternal
polyhydramnios.
b) Plain radiograph: Examine a possible coiled feeding tube in the esophageal pouch and/or an
air-distended stomach.
c) Esophagogram with contrast medium: for demonstration of an isolated TEF (H type)
d) Endoscopy with methylene blue dye: examine possible defects in the esophagus during forced
inspiration.
- Assurance to parents that during the first 5 years of life are difficult but resolves after and
child will continue to have normal life.
- Surgical complication would include anastomotic leaks, refistulization and anastomotic
stricture