Pediatrics Clerkship H&P

Admission date - 22.05.2024

Encounter date - 22.05.2024
Source of information: nother who seems reliable, the patient and the doctor attending for her
lab details

Identifying Information
15 year old female Tekla Merkviladze is accompanied by her mother. The mother is the
primary historian and is deemed reliable but is supplemented by history from the patient as
well

Chief Complaint
My daughter has been vomiting severely

HPI
This is a 15 year old female who was presented to the ER for vomiting that began 3 days ago.
The mother reports that she vomits after every meal and the contents include the food
substances consumed prior. She had a single episode of vomiting 1 month accompanied by the
appearance of brown blood with the vomitus after which she was admitted to the hospital
where she was diagnosed with GERD, following which she consumed the medications
prescribed to her for 20 days and upon stopping these medications the episodes of vomiting
resumed. A similar episode occurred 1 week ago without the presence of blood in vomitus. The
child later reports of experiencing epigastric discomfort along with constipation and the
absence of bowel movement for the past 2 days. Also has nasal congestion and heartburn.

Past Medical History

Antenatal/birth
The patient was born at term 40 weeks weighing 3500 g and length 50 cm to a G1P1. The
delivery was physiologic and had no complications.

Postnatal/Neonatal
APGAR’s are unknown, but mom says she was crying at birth and was also brought to
breastfeed on the first day. The umbilical cord fell on the 4th day. Both mother and baby were
discharged on the fifth day. Tekla did not require any respiratory support or phototherapy
while in the nursery.

Hospitalizations: In August 2023 for gastritis. On April 2024 for GERD and erosive reflux
esophagitis

Surgeries: Underwent tonsillectomy 3 years ago

Illnesses: Diagnosed with ovarian cyst for the past 3 years along with occasional pelvic pain.
Also had common cold 1 week ago
Meds: Took olsepanon and pilobalance for GERD but does not remember dosage
Allergies: NKA

Nutrition/Diet: Was breastfed since the first day exclusively for the first 7 months. Later, she
moved to semi-solid foods such as mashed potatoes and fruits. Disorders related to nutrition
or feeding were not observed.

Habits: No exposure to tobacco smoke in the home.

Immunizations: She is fully vaccinated

Family History
The mother - 48 yo and the father -49 yo. Mother was diagnosed with stomach ulcers while the
father is healthy. Has three siblings(2 sisters and 1 brother) who are also healthy. Does not have
a family history of any genetic or chronic medical conditions.

Social History
The patient lives in Tbilisi with his parents. She is physically active. Follows a balanced diet
consisting mainly of buckwheat, chicken, yogurt and bananas and limits to consuming only 2
meals a day on school days. The mother does not smoke, and there is no smoke exposure in
the home. The patient also does not smoke. They have no pets. There are no sick contacts at
home.

Review of Systems
General: Has no fever, no weight loss but reports decreased appetite
Skin: No rash or erythema
Head: No trauma
Eyes: No discharge, conjunctivitis
Ears: No discharge, tugging
Nose: No nasal discharge is present
CV: Has palpitations and chest discomfort reported to have occurred the previous day and
today.
Respiratory: No cough, wheezing or SOB
GI: Has vomiting and abdominal pain but no diarrhea. Absence of bowel movement for the past
2 days
GU: No dysuria, discharge, pain, hematuria
Musculoskeletal: Moves all extremities equally and has no joint pain or difficulty in movement
Neuro: No seizures
Heme: No easy bruising, bleeding

Physical Exam
Vitals: T-37.2 C, P- 60, R- 18, BP-104/59mmHg, SaO2- 97% on room air
Growth: Wt- 60 kg(99th percentile) Length- 163 cm(98 percentile)
General: The patient is awake and alert
Head: atraumatic, normocephalic; flat anterior fontanelle; no meningeal signs
Nose: no nasal discharge is present
Throat: moist pink oral mucosa, no exudates and uvula is midline
Neck: no lymphadenopathy, no nuchal rigidity noted
CV: RRR, normal S1/S2, no murmurs, gallops, or rubs noted; no thrills or heaves palpated. Heart
tones are clear
Resp: no coughing observed. Percussion shows symmetric resonance and auscultation shows
vesicular breathing
Abd: Pain on palpation over RUQ, RLQ and LLQ. Bowel sounds present and normal. no
hepatosplenomegaly and no masses.
GU: no costovertebral angle tenderness
Ext: symmetric tone, muscle development and strength no signs of hypotonia or hypertonia.
Active and passive movements are painless
Neuro: no atrophy is present and can move all extremities equally.
Skin: moist without any rash, erythema or masses. Skin turgor and elasticity is slightly reduced

Labs/Imaging:

CBC 22/05/2024 24/05/2024 Normal

WBC 5.56 5.67 4.5-13.5 x 10^9/L 38.4 38.2 40-52 %

HCT

MCV 92.8 92 80-96 fL

Decreased hematocrit could be due to loss of blood via vomiting previously

ABG 23/05/2024 Normal

pH 7.32 7.35-7.45

pO2 37 68-108 mmHg

AnGap 9 10-20 mmol/L

HCO3(std) 21.7 - mmol/L

Decreased pH, pO2 and anion gap with normal- elevated bicarbonate levels might indicate
metabolic acidosis which could be secondary to vomiting (loss of gastric acid)
US of abdominal cavity:
Liver - plain contour, cranio-caudal size of the right lobe - 93 mm
N], homogeneous, normal structure
Gallbladder - 64 X 20mm, walls plain, contents - non-homogeneous
Pancreas - outline plain, not sharp, head - 16 mm, body - 13 mm, tail - 18 mm
Homogeneous, echogenicity - average
Spleen - homogeneous, normal structure
Excess gases and liquid content in the intestines
Free liquid - not marked

Cardiac US:
There is vomiting, abdominal pain.
Electrolytes were determined - normal.
Sat - 100% P - 50
Auscultation: a low-pitched systolic murmur with a maximum in the fourth heart area to the left
of the sternum.
Palpation: pulse on the femoral artery with good filling and distension.
Echocardiography:
Changes of bicuspid, tricuspid, aortic and pulmonary artery valves; ventricular and atrial
cavities, septa; pulmonary artery and aortic ducts were not detected:
left ventricular contractility - good;
The pericardial cavity is free of fluid.
Recommendation:
After completing the inpatient treatment course, pulse control: 24-hour ECG and
arrhythmologist consultation as needed
Echocardiography in dynamics considering the clinical course.

ECG done on 22/05/2024:

R-R-1.30-1.10
PQ -0,14
QRS -0,08
QT -0,48/0,44/>0,04
QTI -0.26/0.24/>0.02
P-46-55
<a-+90
Conclusion: sinus rhythm, sinus bradyarrhythmia, vertical cardiac electrocardiogram. position,
e-mail Prolongation of systole by 0.04. Monitored observation is desirable.

ECG monitoring by Holter method:

During the examination, sinus rhythm, respiratory arrhythmia (age norm). 8 supraventricular
extrasystoles were observed.
No episodes of sinoatrial, atrioventricular block and paroxysmal tachycardia were observed
during the study period
minimum sinus rhythm at 34-40 beats per minute at night (respiratory arrhythmia background);
During daytime, the minimum rhythm is in the range of 42-55 beats per minute; Maximum sinus
rhythm is 120 beats per minute during the day
in hours; average frequency of 60 seq/min;

There were no ST segment changes. A negative T tooth is fixed in sections V1-2.

Problem List
1. Vomiting
2. Abdominal Pain
3. Bradycardia
4. Absence of bowel movement (constipation)

Differential Diagnosis

1. Gastroesophageal Reflux Disease (GERD) with possible Esophagitis or Gastritis: Given the
history of GERD and previous diagnoses of erosive reflux esophagitis and gastritis, these
conditions could be contributing to her symptoms. The recurrence of symptoms after
 stopping medication suggests that GERD could be the primary issue. The previous
diagnosis of erosive reflux esophagitis indicates significant acid reflux, which can cause
inflammation and pain.
2. Gastritis and Peptic Ulcer Disease: Given the patient's history of brown blood in vomitus
(possible indication of a gastrointestinal bleed), recurrent vomiting, and epigastric
discomfort, gastritis or peptic ulcer disease should be considered.
3. Gastric Outlet Obstruction: The recurrent vomiting of undigested food, abdominal pain,
and absence of bowel movements may indicate a mechanical obstruction in the stomach
or small intestine.
4. Gastroparesis: Delayed gastric emptying can cause vomiting after meals. This could be
secondary to GERD or an independent condition. Vomiting food consumed earlier
suggests that the stomach is not emptying properly. This condition can be secondary to
long-standing GERD or other underlying issues like diabetes or medication side effects.

Assessment

A 15 year old girl with vomiting, abdominal pain, bradycardia and absence of bowel
movement(constipation)

Work-up

1. Liver Function Tests (LFTs): To rule out hepatic causes of RUQ pain.
2. Abdominal Ultrasound or CT Scan: To assess for structural abnormalities such as
pyloric stenosis, gallstones, or intestinal obstruction.
3. Upper Endoscopy (EGD): To directly visualize the esophagus, stomach, and
duodenum for ulcers, gastritis, or other mucosal abnormalities.
4. Gastric Emptying Study: To evaluate for gastroparesis.
5. Helicobacter pylori Testing: As part of the evaluation for peptic ulcer disease.

Plan

1. Patient should be given symptomatic treatment initially via antiemetics(for nausea and
vomiting) and PPI(For GERD)
2. IV fluids to correct dehydration and electrolyte imbalances from vomiting. 3. Small,
frequent meals and possibly a liquid diet if solid foods exacerbate symptoms. 4. Stool
softeners or laxatives to address the lack of bowel movement

Discussion

A 15 year old female child presents with vomiting, abdominal pain and absence of bowel
movement. The patient reports vomiting after every meal and had been diagnosed with
GERD with erosive esophagitis 1 month prior. Her vomiting episodes, which began three
days ago and occur after every meal, are consistent with the consumption of prior food
substances, indicating a potential upper gastrointestinal tract issue. The presence of brown
blood in her vomitus one month ago raises the possibility of gastrointestinal bleeding,
possibly from a peptic ulcer, especially given her history of GERD and erosive reflux
esophagitis. The familial history is notable for her mother's stomach ulcers, which could
indicate a genetic predisposition to gastrointestinal disorders.
Physical examination reveals pain upon palpation in multiple quadrants of the abdomen,
and CBC shows a slight decrease in hematocrit while ABG indicates metabolic alkalosis,
further supporting a gastrointestinal origin of her symptoms. The abdominal ultrasound
shows excess gas and liquid content in the intestines, suggesting delayed gastric emptying
or a functional bowel disorder. Additionally, the echocardiography and other cardiac
investigations did not reveal significant abnormalities except for sinus bradycardia, making
a primary cardiac cause less likely.

A combination of GERD and gastroparesis could be highly suspected as it would explain the
recurrence of symptoms upon stopping GERD medication, the vomiting of undigested
food, and the presence of excess gas and liquid in the intestines.

Medications(Inpatient):

1. Sodium chloride 0.9% (akulife): 500 ml twice a day IV as needed(For dehydration

due to vomiting)
2. Glycerol for adults-rectal solution: 1 enema per rectum as needed(For absence of
bowel movement)
3. Glycerol for children-rectal solution: 2 enema IV single use(For absence of bowel
movement)
4. Simalgel(antacids-250ml vial)- 15 ml oral(Per Os) daily (For the epigastric pain
possibly due to exacerbated GERD)

Learning Issue

A. GERD

Gastroesophageal Reflux Disease (GERD) is a chronic condition where stomach contents flow
back into the esophagus, causing symptoms and/or complications. This reflux occurs due to the
dysfunction of the lower esophageal sphincter (LES), which normally prevents backflow.

Pathophysiology:
Dysfunction of the LES, transient LES relaxations, impaired esophageal motility, or a combination
of these factors allows acid and other stomach contents to reflux into the esophagus.
Contributing factors include obesity, hiatal hernia, pregnancy, certain medications, and lifestyle
factors (e.g., diet, smoking).

Common Symptoms:
1. Heartburn
2. Regurgitation
3. Dysphagia (difficulty swallowing)
4. Chest pain
5. Chronic cough
6. Laryngitis

Diagnosis
1. Clinical evaluation based on symptoms
 2. Esophagogastroduodenoscopy (EGD) to visualize esophagitis or Barrett’s esophagus
3. pH monitoring to measure acid exposure in the esophagus
4. Manometry to assess esophageal motility

Management
1. Lifestyle Modifications: Weight loss, dietary changes (e.g., avoiding trigger foods), eating
smaller meals, avoiding lying down after eating, smoking cessation.
2. Medications:
3. Proton pump inhibitors (PPIs) (e.g., omeprazole)
4. H2 receptor blockers (e.g., ranitidine)
5. Antacids for symptomatic relief
6. Surgery: Nissen fundoplication or LINX procedure for refractory cases

Complications:

1. Esophagitis
2. Barrett's esophagus
3. Strictures
4. Increased risk of esophageal adenocarcinoma

B. Gastroparesis

Gastroparesis is a condition characterized by delayed gastric emptying in the absence of a

mechanical obstruction. This condition leads to prolonged retention of food in the stomach.

Pathophysiology:
The exact cause is often idiopathic but can include damage to the vagus nerve (e.g., due to
diabetes or surgery), systemic diseases (e.g., scleroderma), or infections. Altered motility may
be due to impaired smooth muscle function, abnormal enteric nervous system function, or
hormonal imbalances.

Common Symptoms:
1. Nausea and vomiting
2. Early satiety
3. Bloating
4. Upper abdominal pain
5. Weight loss

Diagnosis:
1. Gastric emptying study (scintigraphy) is the gold standard to measure the rate of gastric
emptying
2. Breath tests (e.g., C-octanoic acid breath test) as non-invasive alternatives
3. Electrogastrography to assess electrical activity of the stomach
4. EGD to rule out mechanical obstruction
Management:
1. Dietary Adjustments: Small, frequent meals; low-fat and low-fiber diet; liquid nutritional
supplements.
2. Medications:
3. Prokinetic agents (e.g., metoclopramide, domperidone)
4. Antiemetics (e.g., ondansetron)
5. Gastric Electrical Stimulation: For refractory cases
6. Nutritional Support: In severe cases, enteral or parenteral nutrition may be necessary

Complications:
1. Malnutrition
2. Severe dehydration
3. Fluctuating blood glucose levels, especially in diabetics
Relationship Between GERD and Gastroparesis:
1. Delayed Gastric Emptying: Gastroparesis can exacerbate GERD symptoms because food
and gastric contents remain in the stomach longer, increasing the likelihood of reflux. 2.
Increased Gastric Pressure: The delayed emptying increased intragastric pressure, promoting
the backflow of stomach contents into the esophagus.
3. Symptom Overlap: Both conditions can present with similar upper gastrointestinal
symptoms, making diagnosis and management more challenging.

SOAP notes:

23/05/2024
Vital signs:
T- 36.6 C
BP- 87/46 mmHg
RR- 19
P- 55
O2 sat- 99%

Subjective (S):
● Patient reports of having vomited twice after meals the previous day but denies any
episode of vomiting after meal that day
● She denies any sudden onset cough,SOB or reflux
● Complains of persistent epigastric pain/discomfort

Objective(O):
● Patient is conscious and alert. Capillary refill time is 2 seconds
● Auscultation shows bilateral vesicular lung sounds with rhythmic tones and normal heart
sounds
● Abdominal examination shows soft non tender abdomen with pain/discomfort on
 palpation in the epigastric region(RUQ,RLQ and LLQ)

Assessment (A):
1. Recurrent Vomiting likely secondary to GERD with potential exacerbation due to
gastroparesis.
2. Constipation contributes to abdominal discomfort.
3. Sinus Bradycardia with unclear etiology, possibly related to vagal response from vomiting
or a primary cardiac condition.
4. Abdominal Pain in multiple quadrants, likely associated with constipation and GERD.
5. Hypotension (BP 87/46 mmHg), possibly secondary to dehydration from vomiting. 6.
History of Erosive Reflux Esophagitis and Gastritis.

Plan (P):
Symptomatic Management with:
1. Antiemetics(Ondansetron for vomiting),
2. Proton Pump Inhibitor (PPI)-Resume or start omeprazole or equivalent (for GERD)
3. Laxatives( for immediate relief of constipation)
Monitoring:
1. Vital Signs: Monitor BP, pulse, and respiratory rate regularly.
2. Hydration: Encourage oral fluids, consider IV fluids if BP remains low.
Further Lab Workup:
1. Repeat CBC to monitor hematocrit.
2. Comprehensive Metabolic Panel (CMP) to evaluate kidney function and electrolytes.
3. Gastric Emptying Study to assess for gastroparesis.
4. 24-hour ECG Monitoring and consult with a pediatric cardiologist to evaluate
bradycardia and murmur.
5. Stool tests: Check for occult blood and potential infections.
Dietary and Lifestyle Modifications:
1. Advise small, frequent meals, low in fat and fiber.
2. Avoid foods and drinks that exacerbate GERD (e.g., spicy foods, caffeine).

24/05/2024
Vital signs:
T- 36.5 C
BP- 90/55 mmHg
RR- 19
P- 65
O2 sat- 98%

Subjective(S):
 ● Patient denies any episodes of vomiting but complains of nausea which started the
previous day
● Still denies cough, SOB or reflux
● Epigastric discomfort persists

Objective(O):
● Patient is conscious and alert and exhibits decreased skin turgor
● Auscultation shows bilateral vesicular lung sounds with rhythmic tones and normal heart
sounds
● Abdominal examination shows soft non tender abdomen with pain/discomfort on
palpation in the epigastric region(RUQ,RLQ and LLQ)

Assessment (A):
1. Nausea: Ongoing, but no vomiting today.
2. Mild Epigastric Pain: Likely related to GERD and possible gastroparesis.
3. GERD: Symptoms managed with PPI.
4. Sinus Bradycardia: Pulse improved from the previous day (55 to 65 bpm).
5. Constipation: No bowel movement despite treatment.
6. Hypotension: Slightly improved but still on the lower side.

Plan (P):
Continue Symptomatic Management with:
ondansetron for nausea and PPI for GERD management.
Continue Hydration by encouraging increased oral fluid intake and by monitoring hydration
status closely.
Constipation Management:
1. Consider increasing the dose or frequency of laxatives in the event of persisting
constipation.
2. Encourage dietary adjustments to include more fiber and fluids.
3. Consider a different laxative if glycerol is ineffective.
Monitoring:
1. Continue to monitor vital signs, with a focus on BP and pulse.
2. Reassess abdominal symptoms regularly.
Further Workup:
1. Await results of previously ordered tests (if any).
2. If constipation persists, consider abdominal X-ray to rule out impaction.