Case Study: Newborn with Vomiting and Diarrhea

A three-day old male infant is brought to the ER by his 22-yr-old mother with vomiting and diarrhea. Diagnostic results will be released upon request, with the final reveal in one week.

Updated:  

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Case Study: Newborn with Vomiting and Diarrhea

Chief Complaint

A three-day old male infant is brought to the ER with vomiting and diarrhea by his 22-yr-old white mother. The mother states, "It started yesterday. He sleeps all the time, but when he's awake he just won't stop crying and I can't get him to stop throwing up after he eats.” This is the mother's first pregnancy. The infant was full term and there were no complications during the lady partsl birth. A full assessment is performed, and the infant is admitted to the hospital.

Assessment Findings

  • Depressed fontanels
  • High-pitched cry lasting more than 5 minutes.
  • Moro reflex is hyperactive.
  • Mild tremors when disturbed.
  • Increased muscle tone, no excoriation of chin, knees, elbows, toes or nose, myoclonic jerks present. Yawns frequently. No nasal stuffiness, nasal flaring or sneezing apparent.
  • Skin is dry with no mottling. 

Vital Signs

  • BP 89/60 RA, lying
  • HR 110 bpm
  • RR 70/min with no retractions
  • T 101o F
  • O2 sat 98%
  • Weight at birth 5 lbs 6 ounces
  • Current weight: 5 lbs 4 ounces

What's going on here?

What other information do you need?

What labs do you want?

What other diagnostic tests should we run?

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in Community and Public Health, Addictions Nursing.

Oooh a pedi case! 

I'm thinking infectious disease vs. congenital disorder. I'd need labs from both mom and baby to help determine that. For mom, I'd double check her immunology labs, especially Group B Strep. For baby, I would want a septic work-up and the results of the Newborn Screening Panel. 

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Specializes in Nurse Leader specializing in Labor & Delivery.

I responded at the help desk. I don't want to say what I think or what I would do, because I'm afraid I will give it away. But I can tell you I'm pretty sure I knew immediately what it is, based on infant's presentation. I would just need to interview the mom for confirmation.

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Specializes in Education, Informatics, Patient Safety.
6 minutes ago, klone said:

I responded at the help desk. I don't want to say what I think or what I would do, because I'm afraid I will give it away. But I can tell you I'm pretty sure I knew immediately what it is, based on infant's presentation. I would just need to interview the mom for confirmation.

You’re on the right track- more info coming soon!

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Following with interest! 

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Maternal History

  • Prenatal care?
  • Maternal past medical history
  • Maternal substance use (recreational and medicinal)?
  • Maternal serology (GBS, HSV, immunology, serology)?

Infant History & Assessment Findings

  • How frequent is the diarrhea?
  • How, how frequently, and what is the infant being fed?
  • Relationship of vomiting and feeding?
  • Back arching or rigidity?
  • How many diapers per day?
  • Skin assessment findings (color, lesions)

Additional Labs & Diagnostics

  • Point of care glucose
  • Basic metabolic panel (including bilirubin)
  • Complete blood count
  • Coombs
  • Four extremity blood pressures
  • Meconium toxicology screen

Consider (Depending Upon Maternal and Prenatal History)

  • Abdominal radiograph
  • Abdominal ultrasound
  • Cranial ultrasound
  • Blood culture
  • Lumbar puncture
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Specializes in Education, Informatics, Patient Safety.
15 minutes ago, chare said:

Maternal History

  • Prenatal care?
  • Maternal past medical history
  • Maternal substance use (recreational and medicinal)?
  • Maternal serology (GBS, HSV, immunology, serology)?

Infant History & Assessment Findings

  • How frequent is the diarrhea?
  • How, how frequently, and what is the infant being fed?
  • Relationship of vomiting and feeding?
  • Back arching or rigidity?
  • How many diapers per day?
  • Skin assessment findings (color, lesions)

Additional Labs & Diagnostics

  • Point of care glucose
  • Basic metabolic panel (including bilirubin)
  • Complete blood count
  • Coombs
  • Four extremity blood pressures
  • Meconium toxicology screen

Consider (Depending Upon Maternal and Prenatal History)

  • Abdominal radiograph
  • Abdominal ultrasound
  • Cranial ultrasound
  • Blood culture
  • Lumbar puncture

Excellent questions! More data coming soon!

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Specializes in ED, med-surg, peri op.

This one has lost me. Most babies I see with D+Vs have some sort of viral infection and are dehydrated. But I don’t think this is the case. 

this is frustrating  

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I am not clear how to post an answer to the Admin help desk. Do I open a new topic? 

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Specializes in in primary care pediatrics and NICU.
On 12/30/2020 at 2:17 PM, chare said:

Maternal History

  • Prenatal care?
  • Maternal past medical history
  • Maternal substance use (recreational and medicinal)?
  • Maternal serology (GBS, HSV, immunology, serology)?

Infant History & Assessment Findings

  • How frequent is the diarrhea?
  • How, how frequently, and what is the infant being fed?
  • Relationship of vomiting and feeding?
  • Back arching or rigidity?
  • How many diapers per day?
  • Skin assessment findings (color, lesions)

Additional Labs & Diagnostics

  • Point of care glucose
  • Basic metabolic panel (including bilirubin)
  • Complete blood count
  • Coombs
  • Four extremity blood pressures
  • Meconium toxicology screen

Consider (Depending Upon Maternal and Prenatal History)

  • Abdominal radiograph
  • Abdominal ultrasound
  • Cranial ultrasound
  • Blood culture
  • Lumbar puncture

Yay, babies!  -now you're speaking my language.  So, agree with above labs. Septic work up warranted. I however, would not do radiology yet.  Except CXR in ED.  

first get CBC, man diff, CMP, CRP, Ammonia; Fractional Bili;  ABG with Lactate.  Surface Cultures; (maybe TORCH too); UA/UC by cath; LP and Bld Clx.  eventually repeat NBS.  Sounds like a lot of labs, but will help eliminate  some DDs.  

1. How long membranes ruptured and intrapartum Abx- how many doses?  2. Mom's HSV status is sometimes unknown, but ask.  Who's been in contact and kissing your baby? (looool).  use the term "cold sores". 

Will post my tentative Dx on admin. Hopefully I'm working in the right direction.  : ) 

 

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Specializes in Education, Informatics, Patient Safety.

Thank you for your patience! I know you want a lot of labs and tests, but I wonder if after reading this second update below you'll know exactly what it is?

After the infant is admitted for dehydration, the nurse observes the mother breastfeeding. The infant demonstrates excessive sucking and poor feeding. He regurgitates 3x after feeding. While the mother is in the bathroom, the nurse observes one episode of projectile emesis. Diaper change reveals loose, seedy curds. The infant sleeps less than 2 hrs after feeding.

Over the next few days, the nurses become concerned at erratic behavior by the mother. She disappears for long periods of time and appears to be lethargic and uninterested in her infant’s well-being. The social worker is called in - he has a long talk with the mother, who finally admits to abusing hydrocodone during her pregnancy.

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Specializes in Nurse Leader specializing in Labor & Delivery.

Thanks for the update; I see my original diagnosis was on the money. ?

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