Department of Surgery

Name: 189 Gotera. Chloe Lynn

Batch/Section: NMD 4 Group 4
Date: December 10, 2022
Preceptor: Dr. Angelica Mary Joan A. Labradores
DAY 2 ACTIVITY
Diagnosis and Management

Case:
A 5day old male infant was noted by the mother with episodes of vomiting of previously ingested milk a few minutes after ingestion. Patient has been vomiting since 2nd day of life and is now noted with minimal
urine output and sunken eyeballs. No changes in bowel movements, jaundice, nor abdominal distension. Patient was then brought to the ER hence this consult.

Patient was born to a G2(2-0-0-2) 28year old mother in a nearby lying in via NSVD. Term, 38weeks AOG, Appropriate for Gestational age.
Mother has no known comorbidities
Patient’s father being the only sexual partner
No previous surgeries. No known food and drug allergies
Not a known alcoholic beverage drinker nor smoker. No history of illicit drug use.

General Survey Vital Signs Skin HEENT Neck

GCS 15, Awake, ambulatory, not in 142bpm No gross lesions, warm and dry (+)sunken eyeballs Trachea midline
respiratory distress
Physical 35cpm Anicteric sclerae No enlarged cervical nodes
Examination 36.7C pink palpebral conjunctivae No masses
Findings Weight: 2.9 kg Height: 52 cm
98% O2 saturation

Lungs Heart Abdomen Genitalia/Rectum Extremities Neuro

Equal chest PMI at 4th ICS MCL, Distinct Distended, soft, tympanitic, nontender, No gross lesions,(+)patent anus, No edema, full peripheral pulses GCS 15 (E4V5M6), 3mm EBRTL
expansion, Clear heart sound, no murmur (+)palpable 2cm mass over the Right tight sphincteric tone, no mass or
No localizing signs
Breath sounds, no Upper Quadrant area lesion, no fecal matter on
wheezes, no stridor examining finger No sensory cut off

5/5 Motor strength

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 Department of Surgery

Instructions:
● Use Schwartz’s Principles of Surgery 11th edition, Sabiston Textbook of Surgery 21st Edition, MIMS, and Bate’s Guide to Physical Examination and History Taking as your reference for this case.
● Indicate the reference and page number in the column provided for your answers.

On 7th day of life, you are still correcting hydration. Patient noted with the following findings:

GCS 15, Awake, alert, not in respiratory distress

156bpm – tachycardia
34cpm – bradypnea
37.1C
98% O2 saturation

Flat anterior fontanelle, moist oral mucosa

Clear breath sounds
Soft, slightly distended abdomen, (+)palpable 2cm round, well-delineated, firm, mobile mass over the right upper quadrant

NGT output: 50cc x 24hrs, gastric

UO: 1.2cc/kg/hr

Hgb 16.3g/dl

HCT 0.50

WBC 9.8
Neu 76
Plt 320
Na 132 (135-145)
K 3.0
Crea 112

ABG: Hypokalemic hypochloremic metabolic alkalosis

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 Department of Surgery
CXR: Unremarkable cardiopulmonary findings

Abdominal Xray Upright/Supine: dilated stomach with tube noted in the body of the stomach. Multiple dilated bowels noted. No air-fluid levels identified. No serosal thickening of the bowels noted. To consider
Ileus.

Ultrasound of the stomach: A prominent pyloric area of the stomach with muscle thickness measuring 5 mm on the transverse view with a length of 20 mm on the longitudinal view suggestive of pyloric
stenosis

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 Department of Surgery

TASK/QUESTION ANSWER REFERENCE

(source, page no.)

What are the pertinent information in the patient ● 156 bpm – tachycardia Schwartz's Principles
upon reassessment? ● Flat anterior fontanelle of Surgery 11th ed
● Moist oral mucosa Chap 39 p 1722
● Soft slightly distended abdomen
● Palpable 2cm round, well delineated, firm, mobile mass over the right upper quadrant Sabiston Textbook of
● NGT output: 50cc x 24hrs, Gastric Surgery 21st ed Chap
● UO: 1.2 cc/kg/hr 67 p 1855
● Na: 132
● K: 3.0 Nelsons Textbook of
● ABG: Hypokalemic Hypochloremic Metabolic Alkalosis Pediatrics 21st ed
● Abdominal X-Ray Upright/Supine: Chap 355 p 1946
○ Dilated stomach with tube noted in the body of the stomach
○ Multiple dilated bowles noted
● · USD Stomach:
○ Prominent pyloric area of the stomach with
○ Muscle thickness 5 mm on transverse view
○ Muscle Length 20 mm on longitudinal view
○ Suggestive of pyloric stenosis
What are the pertinent information in history and PE ● Pertinent data Schwartz's Principles
pointing towards Hypertrophic Pyloric Stenosis? ○ It is most common between the ages of 2 and 8 weeks. Boys are affected four times more often than girls, of Surgery 11th ed
with first-born male infants being at highest risk Chap 39 p 1722
● Hx
○ Px is experiencing non bilious vomiting Sabiston Textbook of
○ Surgery 21st ed Chap
● PE 67 p 1855
○ (+)palpable 2 cm mass over the Right Upper Quadrant area
○ Soft slightly distended abdomen Nelsons Textbook of
○ NGT output: 50cc x 24hrs, Gastric Pediatrics 21st ed
○ UO: 1.2 cc/kg/hr Chap 355 p 1946
● Labs:
○ ABG: Hypokalemic hypochloremic metabolic alkalosis

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What is your current working diagnosis?
Department of Surgery
○ Abdominal X-Ray Upright/Supine:
■ Dilated stomach with tube noted in the body of the stomach
■ Multiple dilated bowels noted
○ Hyponatremic
○ K: 3.0
○ Ultrasound of the stomach:
■ A prominent pyloric area of the stomach with muscle thickness measuring 5 mm on the transverse
view with a length of 20 mm on the longitudinal view suggestive of pyloric stenosis
Mild dehydration secondary to upper gastrointestinal obstruction secondary to congenital hypertrophic pyloric stenosis Schwartz's Principles
of Surgery 11th ed
Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946
What is the dehydration classification of the patient Schwartz's Principles
upon reassessment? of Surgery 11th ed
Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946

● The patient is experiencing mild dehydration

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 Department of Surgery
○ fontanelle: sunken (flat)
○ tachycardic

What are the signs and symptoms of dehydration ● Sunken eyeballs Schwartz's Principles
present in the patient? ● Flat fontanelle of Surgery 11th ed
● Tachycardic Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946
How do you explain the ABG finding of ● The cardinal findings in pyloric stenosis are dehydration, metabolic alkalosis, hypochloremia, and hypokalaemia. Schwartz's Principles
hypochloremic, hypokalemic metabolic alkalosis in Loss of gastric fluid leads to volume depletion and loss of sodium, chloride, acid (H+) and potassium. This results in a of Surgery 11th ed
patients with HPS? hypokalemic, hypochloremic metabolic alkalosis. The kidneys attempt to maintain normal pH by excreting excess Chap 39 p 1722
HCO3.The kidneys attempt to conserve sodium at the expense of hydrogen ions, which can lead to paradoxical
aciduria. In more severe dehydration, renal potassium losses are also accelerated owing to an attempt to retain fluid Sabiston Textbook of
and sodium. Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946
How do you explain the dilated bowels of the ● The dilated bowels of the patient are due to electrolyte imbalance Schwartz's Principles
patient? of Surgery 11th ed
Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946

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 Department of Surgery
How soon will you operate on this patient? ● As soon as the patient is stabilized thru fluid resuscitation and improvement of symptoms Schwartz's Principles
of Surgery 11th ed
Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946
What is the surgical plan? ● Pyloromyotomy Schwartz's Principles
of Surgery 11th ed
Chap 39 p 1722

Sabiston Textbook of
Surgery 21st ed Chap
67 p 1855

Nelsons Textbook of
Pediatrics 21st ed
Chap 355 p 1946
***The preceptor may have the option to add more questions or revise the task in the table.

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