Vomiting in the Pediatric Age Group

Neil Mullen

Disclosures

Pediatr Health. 2009;3(5):479-503. 

In This Article

Case Report

Chief complaint: fall from 3 feet and vomiting.

History of Present Illness

Patient 'DF' is a 6-month-old healthy male with no significant past medical, surgical or birth history who is brought to the emergency department (ED) by ambulance after an unwitnessed fall from bed (approximately 3 feet off the ground) onto a carpeted floor at 16:30. The child's mother reported that she heard the fall, which was immediately followed by crying, and that the child was fully alert from when she entered the room several seconds later. A total of 2 h after the incident, the patient had one episode of nonbloody, nonbilious vomiting, at which point the emergency services were called. The child's mother reported that changes in the child's behavior consisted of increased tiredness and fussy behavior since receiving the 6-month immunizations on the day prior to the incident, but no noticeable behavioral changes since the fall. The child was otherwise without complaint.

Review of Condition (As per Mother):

  • General: generally healthy;

  • Dermatological: no rashes;

  • Head/ears/eyes/nose/throat: no rhinorrhea, hears normally;

  • Pulmonary: no cough or audible wheezing. No difficulty breathing;

  • Gastrointestinal (GI): vomiting (see history of present illness). Feeding normally up to the time of the incident;

  • Genitourinary: normal urine output;

  • Past medical history: full-term product of an uncomplicated pregnancy and delivery;

  • Past surgical history: none;

  • Medications: none;

  • Allergies: none.

Physical Examination Findings

  • Vitals: blood pressure: 96/56 mm Hg; heart rate: 134 bpm; respiratory rate: 22 bpm; SaO2: 100%; temperature (rectal): 99.4°F; weight: 6 kg;

  • General: patient is sitting up on gurney (unassisted), holding a bottle, dressed only in a diaper with no obvious signs of trauma. Patient tracks the physician around the room with both eye and head movement. Patient is well nourished, well appearing and in no acute distress;

  • Skin: pink, warm and dry with no rashes or petechiae;

  • Head: normocephalic/atraumatic. No hematomas, bruises or abrasions;

  • Eyes: pupils equal, round, reactive to light, extraocular movements normal with normal sclera and conjunctiva;

  • Ears: tympanic membranes clear bilaterally with no blood or cerebral spinal fluid (CSF) noted;

  • Nose: no nasal discharge;

  • Mouth: moist mucus membranes. Appropriate dentition for 6 months. Stable jaw and midface with no signs of trauma;

  • Neck: supple with no palpable nodes and no apparent tenderness to palpation over spinous processes;

  • Cardiovascular: regular rate and rhythm;

  • Lungs: clear to auscultation;

  • Abdomen: scaphoid, soft, nontender with normal bowel sounds;

  • Back: normal spinal alignment with no step-off or apparent bony tenderness;

  • Genitourinary system: normal circumcised male. A large lymph node could be palpated in the left inguinal crease;

  • Neurologic: normal motor, sensory and cerebellar function for age.

ED Course

Patient had another episode of nonbloody, nonbilious emesis in the ED. A noncontrast CT scan of the head was ordered; this was read as normal by radiology. Patient was observed for several hours. The patient had three more vomiting episodes. At that time, an intravenous drip was placed with 120 cc normal saline (NS) infused (20 cc/kg) and blood drawn; x-rays of the abdomen were ordered.

Laboratory Statistics

  • Complete blood count: white blood cell: 6.700/µl, with 54% PMNs. Hemoglobin: 12.4; hematocrit: 39%;

  • Electrolytes: Na+: 134; Cl: 109; K+: 4.3; HCO3 : 21; Cr: 0.6; BUN: 8; Glu: 111;

  • Liver function test: alanine aminotransferase: 92; aspartate aminotransferase: 73; alk phos: 357;

  • Lipase: 28;

  • Acute abdominal series: nonspecific bowel gas pattern with air in colon. No free air on left lateral decubitus x-rays.

At this time, the patient had one episode of bilious vomiting and it was decided to admit the child for intravenous hydration and bowel rest. He was re-examined. He was less attentive and the mother reported poor feeding since presentation to ED. His diaper was removed and a tender, 2 cm left inguinal mass was noted, which now extended into the upper scrotum. The right testes was descended and normal - the left testicle could not be palpated. An attempt was made to reduce inguinal mass without success and surgery was consulted. An ultrasound of the inguinal area was carried out, which confirmed a left inguinal hernia and showed good blood flow to the left testicle. The hernia was reduced under sedation. Patient was then admitted to surgery for observation with elective left inguinal hernia repair to follow in the morning.

Diagnosis Left inguinal hernia.

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