Head to toe Pediatric Assessment including Developmental Progress
A. Patient Episode
J.R. is an alert and active, 3 month old male brought into the emergency room by his mother for concerns about him not tolerating his feeds.
Source and Reliability: Mother (mom).
B. SOAP
Subjective data.
Patient Age and Gender: 3month ex 32 week old male
Chief Complaint: “he keeps spitting up after he drinks breast milk or formula and even after he has burped”
History Present Illness: The mom explains that the “spitting up” occurs immediately after feeding J.R. and started about a month ago. She made sure to burp him after every two ounces of milk. She pumps the breast milk and then feeds him from a bottle in order to have a better idea of how much milk he is consuming. He has been drinking both formula and breast milk since birth in order to supplement and to help him gain weight. Mom estimates the amount of spit up to be less than half an ounce. The spit up is described as non-bilious non-bloody fluid with no foul smell. The mom denied that J.R. experienced any cough, diarrhea, or fevers with his spitting up. She described that J.R. had seemed more irritable to her during and after feeds because he would become “fussy and start crying”. Mom denied any sick contacts.
Significant Past History:
Pregnancy: Mom had a preterm labor, J.R. was born at 32 weeks and was the first born.
Newborn Period: Born vaginally at 32 weeks, Apgar score of 6. NICU stay: DOL #1 till 4 weeks. Birth weight was 1.8 kg. Extubated DOL# 7
Illnesses: Esophageal atresia. Iron deficiency anemia. Surgeries: repair of esophageal atresia at 1 month of age. Hospitalization: 1 month in NICU.
Accidents: Mom denies any injuries or trauma.
Preventive care: Vaccines UTD. Last PMD visit was last week where some loss of weight was noted. Patient now weighs 3.63 kg. Prior PMD visit was 4 kg. PMD recommended that mom increase amount of formula in order to assure patient consumed appropriate amount of calories.
Significant Family History: Denies significant family history.
Developmental History: J.R. sucks and swallows well during feeds, smiles in response to mom’s voice. Turns his head in the direction of noise. Cries and coos.
Current Medical History: Denies any sick contacts.
-Allergies: Denies any allergies.
-Current Medications: One multivitamin once a day and ferrous sulfate twice a day.
Significant Review of Systems:
General: Mom reports a weight loss of one pound between monthly PMD visits. Mom reports weight loss occurred after the patient began becoming irritable during and after feeds with “spitting up” episodes.
Skin: Denies any noted skin rashes, lesions, masses, or dryness.
HEENT: Head: Denies any trauma. Eyes: Denies any issues with vision. Ears: Denies any issues with hearing.
Nose: Denies any noted difficulty breathing, stuffiness, or runny nose. Mouth: Mom frequently notices J.R. has spit up after his feeds when fluid dribbles down from his mouth.
Respiratory: Denies any noted difficulty breathing or coughing.
Gastrointestinal: Regular bowel movements. Denies any diarrhea or bloody stools. Denies any constipation. Last bowel movement was earlier in the day. J.R. eats 6 ounces of breast milk or formula every 3 to 4 hours. Denies any noted trouble with swallowing. “Spitting up” episodes started about a month ago and occur during and after feeds. Denies any change in formula since birth. Mom consumes dairy twice a week into her diet.
Urinary: Denies any decrease in wet diapers. 8-10 a day is J.R.’s normal. Denies any prior urinary tract infections.
Objective Data.
J.R. is an awake and alert 3 month male who is smiling and cooing at his musical mobile hanging in his crib. He appears calm and comfortable. He occasionally turns his head to his mother’s voice when she is answering questions.
Physical Exam:
Vital Signs: Height: 50.8 cm. Weight: 3.63 kg HC: 24.5 cm. BP 86/54 Right Leg, Heart Rate 140 and normal sinus rhythm, respiratory rate 40, temperature 37.4 degrees Celsius (axillary). No signs of pain.
Skin: Generalized skin is clean, dry and intact. No signs of edema, redness, masses, bruises, scarring or rashes. Generalized skin pink in color, warm to touch, moist mucous membranes.
HEENT: Head: Normocephalic, no lesions or masses palpated. Eyes: PERRLA, symmetric, Pupils 2 to 3 mm constricting. Discs difficult to visualize, no hemorrhage noted. Ears: pinna clear of any drainage, mass, edema, or redness, no external abnormalities; External canals and tympanic membranes without presence of drainage, mass, redness or swelling. Nose: nares clear bilaterally of any mass, drainage, edema; septum midline. Mouth: moist mucous membranes. Tongue symmetric without evidence of edema, mass, or lesions; unable to assess uvula and tonsils.
Neck: Supple, patient turns head side to side as mother moves from one side of crib to the other. Midline trachea, no thyroid palpable.
Lungs: Good expansion. Clear to auscultation, with no audible wheezing, rales, or rhonchi. No apparent dyspnea, tachypnea, or retractions noted. No cough or congestion noted.
Abdomen: distended but soft and no signs of tenderness to palpation. No masses or lesions noted. Bowel sounds heard in all four quadrants. Tympanic to percussion throughout the abdominal cavity. Unable to percuss spleen, liver or kidneys. Spleen, liver, and kidneys not palpable.
Assessment.
1. GERD (Gastroesophageal reflux disease)
The data that supports GERD as the primary diagnosis is the “spitting up” episodes which the mom reports the patient has had for a month with the associated symptom of being colicky and irritable during and after feeds. The patient also has an underlying history of esophageal atresia and being a preemie. Poor weight gain is also noted in the patient. According to Aceti and Corvaglia (2010), typical symptoms are frequency and degree of regurgitation, vomiting, feeding intolerance, crying between feeds, hiccupping, and back arching. GERD includes underlying complications such as esophagitis which causes irritability in many infants. This is what differentiates simple GER and GERD which includes symptoms to developed complications. In addition, Aceti and Corvaglia (p. 405, 2010) report, “incidence of GER in preterm infants is believed to be higher than that in term infants”. In another article regarding GERD, Di Pace, Caruso, Catalano, Casuccio, Cimador, and De Grazia (2011), state that gastroesophageal reflux (GER) and dysmotility are frequently seen in patients treated for esophageal atresia. In this scenario, J.R. was born early at 32 weeks and had a history of esophageal atresia which supports the possible diagnosis of GERD. The patient presented with the majority of these symptoms and was fed by formula in addition to breast milk.
2. MILK PROTEIN ALLERGY:
The “spitting up” episodes reported by mom could be due to an allergic reaction. According to Allen, Davidson, Day, Hill, Kemp, Peake, Prescott, Shugg, Sinn, and Heine (2009), there is increasing evidence of an existing association between GERD and cow’s milk allergy. The reason that milk-protein allergy is presented as the second possible diagnosis is because it is a known differential diagnosis of GERD and it also has the similar symptom of vomiting. The rationale for it not being the primary diagnosis is due to the fact that there were no other evident symptoms supporting that it was a cow’s milk allergy. Some other symptoms related to cow’s milk allergy are diarrhea, eczema, and urticarial which were not reported in this scenario. Allen et. al (2009) validates that breast milk can contain intact cow’s milk antigens which can cause an allergic reaction in the infant. In addition, Allen et. al (2009), explains that Cow’s milk protein-induced gastro-oesophageal reflux disease (GORD) can present with the clinical features of frequent regurgitation and poor feeding.
3. OBSTRUCTION:
Obstruction is listed as a differential diagnosis of GERD in infants which can cause vomiting and irritability.
