Case study...Peds...GI

[hopefornursing]

Hey all,

Been assigned a case study for Peds....

Would appreciate any insight, but I will tell you what I have thought of thus far and am trying to narrow it to top two choices.....We were to try to come up with possible Dx and tests we might anticipate ordered, etc...

Number one dx would be Hiatal Hernia although not too frequent in kids

Numer two dx GERD But i wonder if it's not something more since it's unresponsive to on H2 and two PPI's...

Tests I would anticipate would be another barium swallow, a gastric motility, perhaps a 24 hour pH, maybe an H. Pylori breath test...

Here are the details that were given to us, I want to see if I am missing anything, Thanks!!

7 year old male, 59 pounds, normal neuro signs. C/O daily regugitation post meals, up to 20 times per day, quantity usually a mouthful...Sometimes vomitus in nature and sometimes undigested from meals 4 hours prior.

Unresponsive to Zantac, Prevacid and Prilosec. Prior dx of reflux at age of two with a barium swallow. Hx of occasional bouts of wheezing Tx with albuterol..

I am trying to give this my best shot, but it seem too vague??? Any thoughts would be greatly appreciated!!!

Thanks!

[hopefornursing]

Well, I turned it in, thanks to everyone who helped me think it thru...I put as my first probable dx slow gastic motility and that tests that could be anticipated would include a gastic motility study, and a 24 hour pH study as well as endoscopic eval of the esophagus.....

And the correct answer,,,as per the instructor.....Drum roll please,,,,

something I really hadn't considered much, and none of us got it right,:angryfire

constipation.

Which is curious, as there was really no indication of a problem in the info we were given that would have led us to that......Good thing it wasn't graded....

HOW could constipation possibly cause repeated regurgitation over a period of months.

I am really curious about that and the instructor didn't have time to discuss....

I guess they want us to think outside the box.....

Thanks :redpinkhe

[FlyingScot, RN]

Well now that's just ridiculous. The first sign of constipation is lack of bowel movements which wasn't mentioned. In addition if the kid is so backed up that he's vomiting there would be other significant signs like a distended abdomen and abdominal/rectal pain. Anybody here who's been backed up for even a few days can attest to that. While I don't recommend it I'd want to let that instructor know that a bunch of peds nurses with YEARS of experience think that diagnosis is a bunch of hooey!!!!! Although, in the end, you did learn a bunch...I hope!

[hopefornursing]

Well now that's just ridiculous. The first sign of constipation is lack of bowel movements which wasn't mentioned. In addition if the kid is so backed up that he's vomiting there would be other significant signs like a distended abdomen and abdominal/rectal pain. Anybody here who's been backed up for even a few days can attest to that. While I don't recommend it I'd want to let that instructor know that a bunch of peds nurses with YEARS of experience think that diagnosis is a bunch of hooey!!!!! Although, in the end, you did learn a bunch...I hope!

I agree, and i am just a student....I mean, you are a peds. nurse, have you ever, ever ran across a case of persistant regurgitation whose cause was constipation??? And really, for months this had went on, and wouldn't the kid had c/o bloating, distention,leakage and most of all pain? I would never be able to tell this particular instructor that she might be the one that's full of "it" pardon the pun!

And I did learn a bunch, thank you!!!

[leslie :-D]

you know, i truly DID think of partial bowel obstxn...

which is waaaay beyond constipation.

i know you gave us all pertinent data...

and nothing was indicative of "CONSTIPATION"!!

sheesh.

leslie

[hopefornursing]

you know, i truly DID think of partial bowel obstxn...

which is waaaay beyond constipation.

i know you gave us all pertinent data...

and nothing was indicative of "CONSTIPATION"!!

sheesh.

leslie

Doesn't this make you miss nursing school sooo very much?

[FlyingScot, RN]

NOPE!!!!!!!!!!!

[leslie :-D]

Unresponsive to Zantac, Prevacid and Prilosec.

does this mean, the doc missed the mark as well??

seriously, i am so baffled.

leslie

[FlyingScot, RN]

Maybe this is one of those examples about overthinking something but if so it was certainly a lousy one. I, for one, would like to hear the instructors rationale for the answer.

[hopefornursing]

you know, i truly DID think of partial bowel obstxn...

which is waaaay beyond constipation.

i know you gave us all pertinent data...

and nothing was indicative of "CONSTIPATION"!!

sheesh.

leslie

OK

[FlyingScot, RN]

It might show up on a regular x-ray. Doubtful on a barium swallow unless they did a follow through which is watching (with subsequent x-rays) the barium go through the entire GI tract. Might have shown on the enema if the obstruction was low enough.

[Daytonite, BSN, RN]

the first step in diagnosing is pulling together all the abnormal data that you have in front of you. then you look for patterns in the symptoms that lead to clues about possible answers as to the conditions you are dealing with. obviously, there were objective and subjective cues in the case study that were critical to getting to the correct answer. the recognition of the abnormal objective and subjective cues (data) is something we all strive to perfect. to assist you in this there are several publishers that have put together books of signs and symptoms that will help tell you what diseases you are dealing with. here are two of them:

• signs & symptoms: a 2-in-1 reference for nurses
  
• nurse's 5-minute clinical consult: signs & symptoms
  

[hopefornursing]

Ok, we have been given "the rest of the story" by our instructor...

Apparently, when the child finally got to a ped. GI, that is who zeroed in on constipation, and an abd xray was done, which showed significant fecal matter in the intestines.....

Our instructor explained it to us in simple terms, think of a simple plumbing setup, if the bottom pipes are clogged whatever is trying to get thru will have to come out one way or other and since the intestines were slow/constipated/.clogged and the child already prone to reflux d/t previous hx, this is how it manifested....

Guess what the tx was? Miralax.

I guess this was a case of the ped, and all of us nursing students seriously overthinking the whole thing....