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Gastrointestinal In An Infant: Case Study

1206 words - 5 pages

In order to come up with a list of appropriate differential diagnoses, essentially I needed to carry out a good consultation, in the form of history taking and physical examination, with the purpose of obtaining as much relevant information and significant findings as possible. To do so, it was necessary that I communicated effectively with HG’s parents and obtained their consent prior to examining their child, as the patient, being an infant, understandably was unable to talk. In terms of medical informatics, I acquired additional information with regards to HG’s medical history from his medical records.

On initial assessment of his symptoms and signs, it was evident that they were ...view middle of the document...

Abdominal ultrasonography is the main investigation for pyloric stenosis, while for NEC a diagnosis is confirmed by abdominal radiography. I was fortunate to have the opportunity to observe both procedures being carried out on HG, and following that, had discussions with the radiologist and radiographer with regards to interpretation of the imaging findings. From the x-ray, multiple dilated bowel loops with some bowel wall thickening was displayed. Additionally, pneumatosis intestinalis was seen; characterized by a ‘train-tracking’ pattern where the subserosal gas presented linearly within the bowel. This sign is pathognomonic of NEC. The ultrasound also exhibited thickened loops of bowel, particularly in the right abdomen, with accompanying dilated intestines and free fluid in the abdominal region. There was no evidence of a hypertrophied pyloric sphincter. HG’s blood results and test feed outcome was unremarkable. Thus, from the imaging discoveries, the diagnosis was strongly suspected to be NEC.

Management

Treatment of an infant with stage 1 NEC is principally focused on non-operative management. According to established principles, resting of the gastrointestinal (GI) tract is essential in order to assist in the healing process of intestinal inflammation4. This is done by means of putting a stop to all enteral feeds and medications. Following this, a nasogastric or orogastric tube with institution of low intermittent suction is then placed to decompress the GI tract2. Hypotension is frequently seen in NEC, thus intravenous isotonic fluids should be provided to replace any aspirated volume. It is essential to maintain euvolemia and appropriate electrolyte levels as failure to do so may lead to shock with electrolyte imbalances, which include hypochloremia, hyponatremia, and hypokalemia3. Once cessation of enteral feeds takes place, total parenteral nutrition (TPN) or an intravenous dextrose infusion should be initiated and continued throughout the duration of GI tract relaxation, which may last from 10 to 14 days2. It is crucial to start TPN as early as possible with sufficient protein to ensure that the recovering infant’s nutritional and caloric intake is enough to encourage growth, to enable injured tissue to heal, and to sustain positive balance of nitrogen levels3. In this case, HG was commenced on intravenous 0.45% NaCl plus 5% Dextrose infusion at the rate of 23mls/hr and received regular weight monitoring.

Frequent and close monitoring of vital signs should be carried out, as well as blood glucose levels and complete blood counts. It can be challenging to maintain normal glucose levels in infants, thus hyperglycaemia or hypoglycaemia may be observed in patients with NEC2. In this case, the nursing staff made sure to carry out regular observations on HG using the PEWS (Paediatric Early Warning Score) chart, which is aimed at recognizing deterioration in children and subsequently...

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