Quiz 15: Vomiting

Front 1

Johnny is a 25-month-old male who presents to the ED with a 2-day history of vomiting and diarrhea. Dad relays a history of abrupt onset of vomiting that started yesterday around 1 pm. Johnny has had 6 episodes of emesis since yesterday and 3 episodes of diarrhea. The emesis is non-bilious and the diarrhea is described as watery with specks of blood throughout the diarrhea. There are no sick contacts in the home. Vital signs: T 37.1, P 102, R 20, BP 90/60. Physical examination is normal and Johnny has still been tolerating some PO feeds without instant vomiting. What is the most immediate intervention for this patient?

Back 1

no immediate intervention is necessary

Front 2

When to give IV bolus with D5W?

Back 2

confirmed hypoglycemia

used for maintenance fluids

Front 3

WHen to give IV bolus of 0.9% saline?

Back 3

signs of dehydration on physical exam or with vitals

Front 4

When to do surgery consult?

Back 4

Abnormal physical exam, indicated abdominal pathology

Front 5

When to do random glucose test?

Back 5

signs of hypo or hyperglycemia

Front 6

When to do no immediate intervention?

Back 6

tolerating PO feeds

no signs of dehydration

normal vitals

Front 7

Rashid is a 5-week-old baby boy who presents to clinic with 4 days of repeated, forceful, non-bilious, non-bloody vomiting without diarrhea. He has 8 to 9 episodes of vomiting per day immediately following breastfeeding. The episodes started 2 weeks after the entire family suffered from severe viral gastroenteritis. His birth history is uncomplicated (full term, NSVD, unremarkable 30-week ultrasound) and birth weight was 3.6 kg (50th percentile). On exam, his vitals are: T 36.7°C, HR 185, BP 85/45, RR 36, Wt 4.1 kg (25th percentile). On exam, his eyes are moderately sunken without production of tears, his lips are cracked, and his throat is without erythema. His capillary refill is ~3 seconds, and his pulse is thready. What is your first step in management?

Back 7

Intravenous lactated Ringer's solution of 20mL/kg boluses until baseline clinical status is achieved, then 100 mL/kg oral rehydration solutions over next 4 hours.

Front 8

A 6-month-old male comes to clinic with a chief complaint of several weeks of vomiting after large feedings. The vomiting has become blood-streaked, which is when the mom became concerned and brought him in. The baby’s PO intake has been down and he has been losing weight. Abdominal exam is normal, with no masses palpated. What is the most likely diagnosis?

Back 8

GERD

Front 9

Pyloric stenosis characteristics

Back 9

• forceful, projectile, non bilious vomiting
• infants hungry and nurse avidly
• oval mass

Front 10

Gastroenteritis

Back 10

• large watery stools, hallmark of infectious gastro
  
• acute
  

Front 11

GERD characteristics

Back 11

• regurg
  
• infants with overfeeding may have forceful vomiting
  
• severe esophagitis may result in blood streaked emesis
  
• pain may lead to feeding aversion if GERD is severe
  

Front 12

Volvulus characeristics?

Back 12

• blood in stool
  
• bowel ischemia -> severe abdo pain
  

Front 13

Intussusception characteristics?

Back 13

• currant jelly stools
• abdo exam -> sausage like mass due to telescoped bowel

Front 14

You are seeing a 1-month-old male who is < 3rd percentile for weight. He is breastfed every 2 hours and latches on well. However, he has frequent non-bilious episodes of vomiting that have been increasing over the past week despite his mother taking “reflux precautions.” He does not have mucus or blood in his stool. Physical exam reveals a small, olive-sized mass in his abdomen. What is the most likely diagnosis?

Back 14

Pyloric stenosis

Front 15

Cleft palate characteristics

Back 15

difficulty feeding

poor latch

Front 16

Cystic fibrosis characteristics

Back 16

malabsorption (chronic)

loose and malodorous stool

lab test -> elevated sweat chloride

Front 17

Munchausen syndrome by proxy

Back 17

• young children, particularly
• maltreatment

Front 18

A 15-month-old boy presents to the ED in January with a 3-day history of diarrhea. His current weight is 11 kg. He was born at 39 weeks, without any perinatal complications. There is no significant history of travel, sick contacts, or recent changes in diet. The mother notes that he has had only 2 diaper changes over the last day. Physical exam is remarkable for an irritable but consolable infant with tachycardia and normal blood pressure. He is crying without tears and his mucous membranes are dry. His abdominal exam is benign. There is no tenting, and capillary refill is 2 seconds. He is diagnosed with gastroenteritis and started on rehydration therapy. Which of the following statements is true?

Back 18

The work-up for infectious diarrhea for this patient should include a Wright's stain for fecal WBCs, a stool Rotazyme, and a stool sample for culture and sensitivity.