WELCOME

Presented by: Dr.Samia Shihab Uddin

Patient
Particulars:
 Name: Alif Khan
 Age: 5 months
 Sex: Male
 Address: Gazipur,
Dhaka
 Date of admission:
21/11/2011
 Chief Complaint

 Vomits out everything for 10 days

Vomiting – non-projectile
precipitated by feeding
Vomitus –
 Contained milk and water
 Neither blood stained nor bile stained
 Odourless
 No associated fever or loose motion
 Summary of present illness

 Ill since birth

 Vomiting since first day of birth
 Consulted with doctor
 Advice- Syp. Simethicon
 Fate- Symptom not relieved completely
 After 1o days

 Vomiting resumed its original frequency

 Irritable and cried all the time
 Sometimes turned blue
On 13/07/2011 at Mitford Hospital
(age- 15 days)

 Presented with- vomiting, irritability

 Prescribed- Syp. Simethicon
 Advice: Stomach small in size
Must burp after each feed
 On 23/07/2011 at Shishu Hospital
(age- 25 days)

 Chief complaint: persistent vomiting

 O/E: irritable.
Excessive crying
Distended abdomen
 Treatment: Drop Flatulose
 Over the next 2 months

 Vomiting was little bit controlled

 2 visits to doctor at Shishu Hospital

 Drop Domperidon and Drop Cimethicone

 Arousal of concern on 23/09/2011
(age- 3 months)

 Increased episodes of vomiting

 Fever
 Breathing difficulty
 Blue spells
On 23/09/2011, at Shishu Hospital

 O/E- Alif appeared very ill

R/R – 70/min
Dehydration- present
 “Hypertrophic Pyloric Stenosis”- suspected
 Advice:
 Immediate hospitalization
 USG of whole abdomen
 Referred to Ad-Din Hospital
 Ad-Din Hospital Admission
(23/09/11 to 11/10/2011)

On 23/09/2011
 Treatment on admission:
a. Infusion
b. Oxygen inhalation
c. Nebulisation
d. Inj. Ceftriaxone and Amikacin
e. Suppository Paracetamol
 Investigations

23/07/2011
 Random plasma glucose: 12.8 mmol/L
 Serum electrolytes:
Na- 135mmol/L
K- 4.7 ”
Cl- 92 ”
TCo2- 29.6 ”
 Investigations(contd.)

24/09/2011
1. CBC-
 TC OF WBC- 6200/CUMM
 Hb- 10.2g/dl
 MCV- 82.6 fL
 DC- Neutrophils- 30.8%
Lymphocytes- 56.1%
 Platelets- 426000/ cumm
 ESR- 20 mm in the first hour
 Investigations(contd.)

27/09/2011
 Blood c/s – No growth
 Stool R/E- pus cells:1-3/HPF
fat: +
Mucus: +
29/09/2011
 Hb- 9.8g/dL
30/09/2011
OBT- Negative
X-ray chest on 24/09/2011

 Comment: Pulmonary
inflammatory lesions
X-RAY CHEST ON 6/10/2011

 Comment: Pulmonary
lesions with right
pleurisy
X-ray chest(right, lateral view) on
09/10/2011
 Pneumonitis with fluid
containing ring shadow
and pleural effusion(R)
Admission to BMCH on 11/10/2011

Chief Complaints
 Vomits everything out
 Fever
 Breathing difficulty with occasional blue
spells
 Vomiting

 Precipitated by feeding
 Repeatedly in small amounts
 Neither bile nor blood stained
 Not malodorous
 Non-projectile
 Contains milk and water, with little mucus
 Fever

 High grade
 Measured 104 F
 Reduced with Suppository Paracetamol
 No ass. chills or rigor
 Breathing difficulty

 Usually follows vomiting

 Breathing rate increases
 No chest indrawing
 Occasional blue spells
 Worsens with crying
 Other

 Birth history- born normally at term at a clinic

in Gazipur

 Feeding history- EBF

 Immunisation history- acc. to EPI

 On Examination

General Examination
Appearance- Ill-looking
R/R- 60 breaths/min.
H/R- 114/min.
Temp.- 101F
No other abnormalities were detected
 Abdominal Examination

 Inspection-
a. Size and shape- normal(not scaphoid or
distended)
b. Flanks- not full
c. Engorged veins, visible peristalsis, scar
marks- absent
d. Umbilicus- centrally placed and inverted
Abdominal Examination(contd.)

 Palpation: No mass, no rigidity, no

organomegaly
 Percussion: Shifting dullness absent
 Auscultation: Bowel sound audible
Examination of the Respiratory
System
 Inspection:
Size and shape- normal
No chest indrawing
Movement bilaterally symmetrical
 Palpation: No evidence of mediastinal
shifting
 Percussion: Percussion note normal in
intensity
Examination of the Respiratory
System(contd.)
 Auscultation: Breath sound is vesicular
No added sound

No other abnormalities were detected on

examination of other systems.
 Investigations

12/10/2011
CBC
 TC of WBC: 6.9x10 /L
 DC of Neutrophils- 36%
Lymphocytes- 56%
 Hb- 11.5g/dL
 Platelets- 186x10 /L
 ESR- 10 mm in the first hour
PBF: No specific findings
Chest X-ray on 12/10/2011

 Ring shaped cavity

present in lower zone
of right side
 Increased
bronchovascular
markings in the right
side
 No fundal shadow
Chest X-ray on 17/10/2011
 Investigations(contd.)

22/10/2011
 Serum Electrolytes:
Na – 136mmol/L
K – 5.18mmol/L
Cl – 102mmol/L
HCO3 – 25mmol/L

 MT test- Negative
USG ON 29/10/2011

 Minimum Pleural
effusion is noted in
right hemithorax
 Based on clinical &radiological
evidence
 Diagnosis- Tubercular Lung abscess of
the right side
 Treatment Started: 6 months regime
a. Tab. Isoniazid+ Rifampicin
b. Tab. Pyrazinamide
 Overall clinical improvement
As shown by-
 Reduced episodes of vomiting
 No fever
 Normal breathing
 Better feeding
Chest X-rays on 28/10/11 &29/10/11

 Apparent calcification
of TB lung abscess
Clinical and Radiological improvement

Alif was discharged on 02/11/2011

This time on admission to BMCH

 On 21/11/2011- O/E no abnormal findings

were detected in any system
 Next step- Chest X-ray
Alarming find

 NO RESOLUTION OF
APPARENT ABSCESS
CAVITY
 Persistent vomiting-
not even controlled by
Injectable Domperidon
CONTRAST X-RAY ON 14/12/2011
Contrast X-ray
 IMPRESSION

Organoaxial volvulus of stomach

associated with diaphragmatic
hernia
 MANAGEMENT

SURGICAL REPAIRMENT OF Diaphragmatic

Hernia

 Consultation with Surgery Department

 Transfer to Dhaka Shishu Hospital, after
patient was stabilised with appropriate
supportive care.
Latest update
Thank you
THE END