ihps

Welcome to Clinical MeetingPresenter:Dr. Maimuna Sayeed Resident – Phase APaediatric Gastroenterology & Nutrition

Particular of the patient Name: Rafin Age: 40 days Sex: Male Address: Potuakhali Informant: Mother Date of admission: 05/05/201 6 Date of examination: 05/05/2016

Presenting Complaints1. Vomiting since 17 days of age.

History of Present Illness

According to the statement of informant mother, her baby was relatively well till 17 days of age. Then he developed vomiting, after each feed. The frequency of vomiting was 4-5 times initially but it increased to 12-15 times per day later on. The vomiting was projectile and content was whitish, not bile or blood stained.

Cont. After each vomiting baby gets hungry and cries for milk. On query mother mentioned that she noticed a moveable mass on abdomen after each feeding. He used to pass urine 8-12 times at the beginning of this illness but later the frequency of urination decreased to 2-3 times per day and for last 5 days he urinated once in a day and it was high coloured.

Cont. He was loosing weight during the course of illness. There is no h/o fever, reluctant to feed. With these complaints he has got admitted into BSMMU for evaluation and management.

Birth History Antenatal History: Mother was on regular antenatal check up, her antenatal period was uneventful.

Natal History: He was born by LUCS at term with good birth weight (3.7 kg) and cried immediately after birth.

Cont. Postnatal History: His postnatal period was uneventful.

Developmental History He is developmentally age appropriate. Primitive reflexes & partial head lag present, baby stares at mothers face, vocalize with gurgles, smiles briefly when talked to by mother.

Immunization History Immunized is not yet started.

Past Illness Nothing Contributory.

Feeding History Rafin is on exclusive breast feeding.

Family History He is the 1st issue of non-consanguineous parents. No h/o same type of illness in his family.

Socio-economic Condition

They belong to a low socio-economic background. His father is a farmer and mother is housewife. They lives in tin shed house, drinks supply water, uses sanitary latrine.

Travel History Nothing contributory.

Drug History Nothing significant.

Physical Examination

General Examination Appearance: Ill looking, fretful, cachectic

Anaemia: Mild Dehydration: Some dehydration Edema: Absent Jaundice: Absent Cyanosis: Absent Clubbing: Absent

Cont. Koilonychia: Absent Leucoychia: Absent Lymph node: Not enlarged Bony tenderness: Absent Anterior fontanelle: Depressed Suture: Prominent

Cont. Skin survey: Skin pinch goes back slowly BCG mark absent JVP: Not raised Spine: Normal Eye: Sunken ENT: Normal

Cont. Vital signso Temperature: 98 Fo R/R: 24 breaths/mino Pulse: 100 b/min

Cont.Anthropometryo Weight: 2.7kg ( WAZ -3.2)o Length: 57cm (50th centile)o OFC: 36cm (3rd centile)

Alimentary System:Oral Cavity: NormalAbdomen proper:

Inspection- Shape: Normal.Umbilicus: Centrally placed, inverted. There was visible peristalsis on upper

abdomen after feeding & it was moving from left to right.

Flunks not full.

Cont.Palpation-

Abdomen: Soft, non tender, small olive like mass was palpable in left upper quadrant.

Liver: Not palpable Spleen: Not palpable Fluid thrill: Absent

Cont. Percussion- Shifting dullness: Absent Auscultation- Bowel sound: Present

Cardiovascular system Inspection: Precordium normal in shape and size. No visible apical impulse

Palpation: Apex beat felt on left 4th intercostal space, no thrill, palpable P2, Left parasternal heave. Auscultation: First and second heart sound audible on all auscultatory areas with no murmur.

Respiratory system Inspection: Shape and size of chest was normal with bilateral symmetrical chest movement.

Palpation: Trachea centrally placed and normal chest expansion and vocal fremitus

Percussion: Resonant Auscultation: Breath sound vesicular & no added sound.

Genitourinary SystemKidneys: Not ballotable Urinary bladder: Not palpable Renal angle tenderness: Absent Genitals: Normal.

Nervous System Higher psychic function : patient conscious, oriented. Motor function : • Muscle tone normal. • Reflexes normal. • Bilateral planter flexor. Cerebellar function: Intact , so far I could examine Sensory: Intact, so far I could examine Cranial nerves: Intact, so far I could examine

Locomotor System Look: No swelling, redness, deformity or peri-

articular wasting. Feel: No raised temperature or tenderness.

Move: No restriction of movement.

Salient Feature Rafin, a 40 days old boy, 1st issue of non-consanguineous parents, hailing from Potuakhali presented with the complaints of vomiting after each feed since 17 days of age. Vomiting was projectile, content freshly ingested or curd like milk, non- bilious, gradually increased in frequency associated with reduction in urine output.

Cont. Baby had no fever and was never reluctant to feed. Rather, he was very eager to breast feed immediately after vomiting. There is h/o visible moveable mass prior to vomiting. On examination baby looked unwell, fretful, alert, moderately dehydrated, cachectic, vitals are within normal limit, Anthropometry revealed

Cont. severe wasting. Abdomen was soft, not distended with no organomegaly. An olive like mass was palpable in left upper quadrant. On test feeding there was a visible peristalsis on the upper abdomen and it was moving from left to right. Other system revealed nothing abnormality.

Provisional Diagnosis

Provisional Diagnosis Infantile Hypertrophic Pyloric Stenosis (IHPS) with some dehydration

Differential DiagnosisCongenital Duodenal AtresiaGastroesophageal Reflux Disease (GERD)

Point in Favour

IHPS • Male baby• 1st issue• Age of onset: 17d• Vomiting is projectile and

non-bilious• Visible peristalsis which

moves from left to right of abdomen

• Palpable olive like mass in right upper abdomen

Points in Favour

Points Against

Congenital Duodenal Atresia

• Recurrent vomiting soon after birth

• Visible peristalsis which moves from left to right of abdomen

• Vomitus is not bile stained

• No associated congenital anomalies.

Point in Favour

Points Against

GERD • Vomiting immediately after feeding

• Vomiting is projectile.

• Visible peristalsis which moves from left to right of abdomen

• Palpable olive like mass in right upper abdomen

Investigations

Plan of investigation CBC, ESRS. ElectrolyteUSG of Whole AbdomenBarium Swallow & Meal in Trendelenberg positionBarium follow throughPlain X-ray chest & abdomenEchocardiogram

InvestigationCBC Hb ESR TC- RBC PC WBC DC

12.4 g/dl 15 mm in 1st hr 3.65 x 10^12 /L 380 x 10^9 /L 11.5 x 10^9 /L N 47%, L 47%, M 04%, E 02%

Cont.S. Electrolyte Sodium Potassium Chloride T CO2S. CreatininePlain X-ray Chest & Abdomen

119.0 mmol/L 3.84 mmol/L 73.7 mmol/L 18.0 mmol/L 0.6 mg/dl Normal study

Cont.Ultra sonogram of Whole Abdomen:

Stomach: Vigorous peristalsis is seen in the stomach & no passage of food particle through the pylorus during the period of scan.

Cont.Measurement of pyloric part-a. Anterior wall 5.4cmb. Posterior wall 5.3cmc. Length 1.9cmd. Width 1.3cmComment: Suggestive of Hypertrophic Pyloric Stenosis

Final Diagnosis Infantile Hypertrophic Pyloric Stenosis (IHPS) with some dehydration with dyselectrolytemia

Treatment

TreatmentCouncellingDiet: EBFInf. 0.45% NS in 10% dextrose (75ml/kg)

Cont.Consultation with Paediatric Surgeryi. Correction of alkalosis (if any) ,

dyselectrolytemia & dehydration.ii. Surgery: Pyloromyotomy (Ramstedt

Procedure)

Follow up on D2 (06.05.16)

S O A P

Vomiting for 2 times since morning

Appearance: irritableDehydration: No signsH/R: 120 b/mR/R: 32 br/mU/O: 2 times since morning

Static • Continue I/V fluid in maintenance dose

• Repeat S. electrolytes

Follow up on D3 (07.05.16)

S O A P

Vomiting 2-3 times since morning

Appearance: irritableDehydration: No signsH/R: 104 b/mR/R: 28 br/mU/O: once since morning

Static

S. Electrolyte Na 135.6 mmol/L K 2.56 mmol/L Cl 90.7 mmol/L

• Add K+

Follow up on D8 (12.05.16)

S O A P

Vomiting continue after each feed

Appearance: wellDehydration: No signsH/R: 112 b/mR/R: 32 br/mU/O: once since morning

Rehydrated

S. Electrolyte Na 135.0 mmol/L K 4.56 mmol/L Cl 102.0 mmol/L

• Referred to Paediatric Surgery