by Kevin J. Knoop, MD, CDR, MC, USNR, Edward C. Dillon, MD
Chief Complaint:
Vomiting
History of the Present Illness:
A 26 day-old white female presents with a history of nonbilious vomiting for the past two days. The mother states that the patient has thrown up all of her feedings during this time. She has also noticed a decrease in urine output with only one wet diaper in the past 24 hours. Appetite is good and the child seems to be very hungry today. There has been one bowel movement in the past two days. There is no history of fever, rash, congestion, cough, or irritability. The sleep pattern has been unchanged. There are no other family members who are ill at home. Past medical history reveals this patient to be the first born product of an uncomplicated full term pregnancy and spontaneous vaginal delivery.
Physical Examination:
Vital signs are Pulse: 140 beats/minute, respirations: 36 breaths/minute, temperature: 98.3° F (rectal), and weight: 3.9 kg. General impression upon entering the room is of a non-toxic appearing white female who has just vomited a small feeding. The anterior fontanel is slightly depressed. Tympanic membranes are normal in appearance. Nares are clear without congestion. The oral mucosa is slightly dry, pink and without exudates. Neck is supple without adenopathy or meningeal signs. Chest is clear, with normal heart sounds. Abdomen is soft nontender without palpable masses. However, serial physical exam reveals a visible mobile mass which traverses the abdomen in approximately one minute. The mass begins in the left quadrant and moves to the right towards the midline (see photographs). The mobile mass recurs about every 3-5 minutes and is more pronounced after a feeding. Genitalia and extremities are normal. Skin shows no rash or cyanosis.
Laboratory analysis:
Complete Blood Count: WBC: 9.0, HCT: , HGB:12.5 g/dl; Chemistry: Sodium: 134 mmol/l, Potassium: 5.1 mmol/l, Chloride: 95 mmol/l, C02: 31 mmol/l, BUN: 15 mg/dl, GLU: 71 mg/dl, CR: 0.4 mg/dl.
The patient course, diagnosis and discussion
Disclaimer: This article represents the views of the author and is not to be interpreted as official, or representing the US Navy or the Bureau of Medicine.
Photographs: Photographs by Kevin J. Knoop, MD and property of Emergency Medicine Residency Teaching file, Naval Medical Center, Portsmouth, VA.
Acknowledgment: Funding for these educational materials has been provided by Glaxo Pharmaceuticals through a grant to The University of Texas Health Sciences Center at San Antonio.
Funding for color reproduction of the published photographs has been provided through a grant to the publisher by Clinical Communications Inc. of Greenwich CT, a medical education and publishing company that develops educational programs for health care professionals.
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