Rachel O’Brian, MD, INOVA Fairfax Children’s Hospital with Ioannis Koutroulis, MD, Children’s National Medical Center

HPI:

9 month old ex FT male transferred from an outside hospital for abdominal distension and decreased oral intake.  Over the past 3-4 days, parents noticed the patient had become less active, weaker and more fussy.  Parents felt his abdomen was more distended, but denied any fever, emesis, or diarrhea.  His bowel movements had been harder and less frequent, only 1-2 per day and he had decreased oral intake.  Last bowel movement was this morning and “pasty” without blood.

Parents noted the patient had been growing well and developing normally.  Currently taking breast milk in addition to solids, which had been started around 6 months of age.

At the OSH, he had an abdominal x-ray which showed gaseous distension of the colon most significantly involving the sigmoid colon and transverse colon.   Labs were reportedly “normal.” 

ROS:

Gen: no fever; + fatigue, fussiness, and decreased PO intake

ENT: Increased clear rhinorrhea over 2 days, drooling more over the last 24 hours

Respiratory: Denies increased work of breathing or cough

Cardiovascular: Denies color change or cyanosis

Gastrointestinal: Denies vomiting, diarrhea, abdominal pain; + constipation

Genito-Urinary: Denies decreased UOP; normal wet diapers

Musculoskeletal: Denies peripheral swelling

Neurological: + limp and increased blank stares since yesterday, not interactive like normal 

Dermatological: no rashes

Past Medical Hx:

Born full term by c-section

PICU admission at 3 months of age for diarrhea with significant acidosis, AKI, and transaminitis  (recovered and doing well since discharge)

Medications: none

Social Hx: lives with mother and father, no other children in the home.

Allergies: none

Immunizations: UTD

PE: BP 113/79, Temp: 99.4 °F (37.4 °C), Heart Rate: 136, Resp Rate: 44, SpO2: 100 %, Weight: 7.6 kg (20^th%tile)

Constitutional: Fussy but consolable, well hydrated, well perfused

Head:  Normocephalic, anterior fontanelle open and flat

ENT: Moist mucous membranes, no oral lesions appreciated.

Respiratory/Chest: CTAB, no wheezes, rales, or rhonchi.  No tachypnea, no grunting or retractions.

Cardiovascular: Regular rate and rhythm. No M/R/G.  Brisk cap refill

Abdomen: Soft but with moderate distension, no appreciable HSM. Decreased BS

GU: normal rectal exam, no stool in the rectal vault

Neurological: Fussy but consolable, awake and interactive, moving all extremities but laying in father’s arms. Decreased tone in b/l upper and lower extremities. Strength 4/5 throughout

Skin: Warm and dry. No rash

Repeat abdominal x-ray shows decreased gaseous distension of the colon.  You go back to examine the patient and attempt to PO challenge him.  His tone is decreased from prior and he appears to have significant weakness despite being awake.  Dad tries to give the patient a bottle of Pedialyte, but he is unable to latch and he has a weak suck.  His respiratory effort is increased, but he still has clear breath sounds throughout.

Repeat vital signs: BP  88/67, HR 145, RR 60, Temp 98.1 F, SpO2 99% in RA

On re-eaxm, you notice increased WOB with subcostal retractions, lungs CTAB without wheeze, ronchi, rales.

Patient’s BG is 42.  You order a D10 bolus after which BG increases to 65. 

CMP: Na 139, K 4.5, Cl 109, CO2 16, BUN 5, Cr 0.4, Ca 10.5, TPr 6.2, Albumin 4.5, AST 53, ALT 24, Alk Phos 223, TBili 0.6

CBC: WBC 12.99, Hgb 12.6, Hct 38.4, Plts 361

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.