<p>A 10 month old baby boy was running a fever of 101 F and refused to eat or dr
ID: 10153 • Letter: #
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<p>A 10 month old baby boy was running a fever of 101 F and refused to eat or drink for the past 24 hours. The next day the child developed diarrhea and vomiting episodes. The vomiting was unprovoked and occurred every two to three hours. When the concerned parent called the doctor, his advice was to give the child clear fluids for a day or so, and if there were no more vomiting or diarrhea episodes, to slowly introduce solid foods. The infant accepted the fluids, but vomited them within 15 minutes. His diarrhea continued throughout the day. The next day the vomiting continued but the diarrhea stopped. However, the child appeared listless and weak, and refused all liquids. The parents took the baby to the emergency room, wfewe upon examination by the attending physician, he appeared to be physically normal and well developed, with the exceptions of a very dry mouth, sunken eyes, a rapid pulse, and diminished skin turgor.</p><p>1. Despite the examination, how would you explain the physical signs noted?</p>
<p>2. what is the next step regarding treatment?</p>
<p>3. should the child continue to receive oral nutrients at this time?</p>
<p>4. What other tests might you consider running?</p>
<p>5. What electrolyte changes might you expect to find, considering this child's history?</p>
<p>6. What could be the potential causes of these symptoms?</p>
<p>7. What questions would you ask, or have asked the parents upon arrival?</p>
Explanation / Answer
Hi there. Having been through physiology, microbio, and a bit of pathology at the medical level, I can get you started in the right direction, but the specifics of your class will dictate what the instructor wants you to do. Can you provide more detail about the class and case method being used?
For this case, let's consider several things:
1. In babies, several diseases and disorders will manifest with vomiting and refusal to keep down fluids or solids. The most simple of these include an infectious illness, being fed the wrong thing, and a gastrointestinal tract blockage/swelling/disease.
2. In this baby, the GI problem is suspect but because it's a 10 month old child, a GI blockage would've manifested sooner. So start with suspicion of infection. Compounding the problem is the set of several symptoms caused by dehydration (baby is losing fluids...babies are very sensitive to this). These symptoms include listlessness, weakness, very dry mouth, sunken eyes, rapid pulse, and diminished skin turgor. Also note that the exam report says the baby "appeared to be physically normal and well developed." Normal weight/appearance suggests the baby doesn't have a longstanding malnutrition problem or GI tract blockage, but instead something more acute.
Now, going to the study questions:
1. Despite the examination, how would you explain the physical signs noted?
Dehydration will cause all the physical signs. The baby's skin isn't "springy" because of water loss from tissues. Heart rate is elevated due to low blood volume, making it necessary for the heart to pump at a higher rate to get all the tissues oxygenated. Dry mouth & sunken eyes are also indicative of dehydration
2. what is the next step regarding treatment?
Consider that you want to start by proving or disproving your #1 suspected diagnosis, then move down the line to the others. Try to select tests which will distinguish between two possible causes or definitively rule out one. And, you need to treat the symptoms by re-hydrating the baby asap. Consider whether you feel any of these tests and treatments are valuable:
-blood cultures for infectious agents + stool cultures for infectious agents
-IV rehydration therapy (since the baby won't keep anything down)...worth looking this up to get the details on what/how it's done
-scans (e.g. CT scan) with contrast material such as barium (but look up what material you feel is best to use with an infant) to reveal any potential bowel obstruction.
3. should the child continue to receive oral nutrients at this time?
Personally, I'd try to continue giving oral hydration to the degree that it still works. BUT, I don't know that this is the recommended course of action. Try the American Academy of Pediatrics, CDC, NIH, and lookup "oral rehydration of infants" to find the latest recommendations.
4. What other tests might you consider running?
See above; what other tests do you feel are valuable?
5. What electrolyte changes might you expect to find, considering this child's history?
This is a key question. Consider/lookup blood concentrations of the following electrolytes: Na, K, Mg, Ca. The first two are the most important and will definitely be affected. But it's important to know their concentrations inside/outside the cell to answer that. A good reference is Guyton's Physiology.
6. What could be the potential causes of these symptoms?
See above. There may be other differential diagnoses, such as heart or kidney disease, that should be considered. Stick to the most common possibilities, nothing exotic. For example, the baby probably doesn't have SARS or a west African mosquito-bite contracted village disease.
7. What questions would you ask, or have asked the parents upon arrival?
The more questions you ask, the better. Remember that these parents are likely to be hysterical and won't remember every pertinent detail the first time you ask them anything. You want to know any possible detail that could be pertinent, such as recent changes in the baby's diet, exposures, travel, whether they are watering down formula/milk with something else (or with pure water), any tick bites or spider bites or rashes on the baby's skin (or even on their skin), did the find the child sucking on or playing with anything strange lately, changes in household cleaners or chemicals, etc. Much of this will help to eliminate exposure to potential chemicals/toxins so you can focus on the baby's internal problems.
I hope this gets you started. Just email or leave a comment if any further specific info would be helpful!
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