Case Presentation
J.S. is a 13-day-old Hispanic male, presenting to the pediatric emergency department with complaints of vomiting. His mother's chief complaint is "vomiting after feeds for the last four days; it happens after every single feed; after feeding, he vomits if he lies flat; he gags a lot; I took him to the pediatrician who suggested Pedialyte, but he continues to vomit and now it is very forceful." J.S. does not take any daily medications and is healthy otherwise.
History of Present Illness
The mother reports a four-day history of vomiting after feedings. Subsequently, the vomiting is worsened when J.S. is positioned supine after feeding and slightly improved when held upright. The patient has continued to act hungry despite hourly breastfeeding efforts every hour. His mother feels the continued hunger is due to cluster feeding juxtaposed to a "growth spurt" and/or gastroesophageal reflux because the infant's brother presented similarly as an infant. Despite the use of Pedialyte supplementation, the vomiting has been increasingly persistent and now forceful. The emesis is described as non-bilious and clear, and appears as digested milk. The mother states that J.S. is voiding adequately; however, she has noticed less frequent bowel movements. As described by the mother, J.S. is alert, responsive, and comfortable without lethargy or difficulty swallowing. The mother brought J.S. to the pediatric emergency department for evaluation.
Past Medical History
The past medical history for J.S. includes coombs positive with an up-trending bilirubin shortly after birth. He was born full-term without a delivery complication and discharged home from the hospital after two days with his mother. His APGARS were 8 and 9. J.S. was referred to cardiology on the fourth day of life due to the auscultation of a murmur at his pediatrician's office. He was referred to cardiology and diagnosed with a small apical muscular ventricular septal defect (VSD) with a scheduled six-week follow up. The immunizations are up to date.
Development and Growth History
The mother of J.S. was evaluated at the local health department for all prenatal visits and never missed an appointment. She passed her glucose surge test. The health department gave her prenatal vitamins at her first visit when the patient was around six weeks gestational-age; she took them daily as directed. The mother was Group B Strep-positive and was treated with antibiotics intrapartum. J.S. has normal development, growth history and is making significant progress during this newborn period.
Family and Social History
The brother of J.S. is eight years old and carries the diagnosis of trisomy 21 and gastroesophageal reflux disease with a repaired VSD. His father had emesis as an infant that required intervention but is not sure of the name of the condition and management. J.S. lives at home with his mother, father, and brother. The mother stays at home and does not work outside the home, and the father works at a local farming company. Four years ago, the family moved to the United States from Mexico. Spanish is the primary language spoken.
Nutritional History
J.S. is a breast-fed infant with persistent and forceful (i.e., projectile) vomiting. The mother has not supplemented with formula at home, just Pedialyte. In return, the mother states the vomiting worsened. The mother eats a well-rounded diet and has been increasing her water intake to promote her breast milk production. She has no food allergies and restrictions in her diet.
Patterns of Elimination/Stool
The mother reports four to five wet diapers per day; however, she has noticed his diapers seem "less full" over the last 24 hours. His last bowel movement was two days prior to going to the pediatric emergency department. She reports that J.S. normally has bowel movements up to three times a day, which she describes as "normal" newborn stool.
Review of Systems
HEENT. His mother endorses yellow discoloration to eyes since birth and does express that his eyes have become more "yellow" over the last two days. Denies nasal congestion and eye drainage. Denies any difficulty swallowing while feeding.
Teeth. No teeth present. Gums are pink with moist mucus membranes.
Cardiovascular. Mother denies central cyanosis and reports blue discoloration of hands and feet at birth. She denies any sweating during feeding. She denies grunting. There is a report of a heart murmur diagnosed as a small apical muscular VSD.
Respiratory. Mother denies any difficulty breathing and reports no cough or congestion. She states he has no respiratory distress during feeding and denies any mucus production since birth.
Gastrointestinal. Mother reports no abdominal distention. The patient has had non-bilious, non-bloody vomiting for four days that has become forceful for 24 hours. Mother reports no bowel movement in two days, and previously, he was stooling daily. Stool has been yellow in appearance. She denies blood in stool. Mother denies obvious abdominal pain.
Genitourinary. Mother reports that patient has had four to five wet diapers in the last 24 hours that have been "less full" than normal. Yellow in color without a foul smell or dark color. Uncircumcised male, mother denies penile discharge or swelling to scrotum.
Neurological. J.S. has been easy to arouse at home and wakes every two hours to feed. He is alert and opening his eyes more at home over the last few days. She reports no abnormal movements of his body or convulsions.
Musculoskeletal. He has no obvious deformities and moves all four extremities with ease.
Skin. No reported lesions or rashes. Mother reports yellow skin since birth that has become more concentrated to his trunk and face. Nails are without discoloration or abnormalities.
Psychological Status. Mother reports the patient sleeps most of the day and cries when he has a wet diaper or is hungry. Denies lethargy of the infant.
Physical Assessment Findings
General Appearance. J.S. presents awake, alert, and responsive to touch upon examination.
Vital Signs. Temp – 98.7° F (rectal), Height – 47cm, Weight – 3.3kg, Head Circumference – 35.5cm, HR – 155, RR – 32, BP – 78/52, Oxygen Saturation – 99% on Room Air.
Skin. Jaundiced appearance noted to trunk and abdomen. No rashes or skin lesions. Lanugo present with dry, peeling skin to the hands and feet.
HEENT. Anterior fontanel soft and flat. Jaundiced sclera noted bilaterally. The head is normocephalic. No oral lesions or thrush. The nares are patent and without drainage; the oropharynx is moist. The palate is intact. The bilateral tympanic membranes are intact without erythema or exudate, pearly gray in color.
Neck/Lymphatic: Supple neck without lymphadenopathy noted.
Chest/Lungs: Bilateral breath sounds clear to auscultation without increased work of breathing or accessory muscle use. Equal air entry into lung fields. No apnea with normal rate of respirations. No cyanosis. No grunting or distress. No wheezing.
Breast: Nipples intact with normal appearance. Chest flat and symmetrical.
Heart: Regular rate and rhythm, systolic murmur appreciated at the left sternal border. No gallop or rub.
Abdomen: The abdomen is soft and flat; nontender to palpation. Normoactive bowel sounds auscultated in all four quadrants. A small mass was palpated in the epigastric area. No umbilical hernia is appreciated.
Genitalia: Uncircumcised male with bilateral descended testes. No drainage or structural abnormality. No hernias present.
Rectum/Anus: Intact, pink in color. No evidence of trauma or abuse.
Musculoskeletal: No obvious deformity with equal strength and movement in all four extremities.
Neurological: CN II-XII intact.
Lab Values
The pertinent lab values include the following: WBC – 9.6, Hgb – 14.8, Hct – 44, PLT – 555, Glucose – 50, Sodium – 140, Potassium – 5.2, CO2 – 18, Chloride – 106, BUN – 14, Bilirubin – 15.2mg/dL.
Pediatr Nurs. 2021;47(5):256-258. © 2021 Jannetti Publications, Inc.
