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Dyspneic in Diapers

Dyspneic in Diapers. Ryan Surmaitis FOEM CPC Competition LVHN. Chief Complaint. 6 day old male with parents Poor feeding and difficulty breathing. History. Decreased activity Decreased feeding Difficulty breathing Symptoms over the last 24 hours

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Dyspneic in Diapers

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  1. Dyspneic in Diapers Ryan Surmaitis FOEM CPC Competition LVHN

  2. Chief Complaint • 6 day old male with parents • Poor feeding and difficulty breathing

  3. History • Decreased activity • Decreased feeding • Difficulty breathing • Symptoms over the last 24 hours • Difficulty breathing is worse when attempting to feed

  4. History • Full term • Vaginal • No complications • Full prenatal care • UTD immunizations • Breast fed only

  5. Review of Systems Positives Negatives No fevers No cough No rash No nasal discharge No abnormal stools • Decreased wet diapers • Vomiting x 1 post-tussive

  6. History • NKDA • No medications • No daycare • No sick contacts • Lives with parents • No tobacco exposure

  7. Physical Exam Vital Signs • Rectal Temp: 98.4 • BP 113/86 • HR 158 • RR 34 • O2 SAT 95%

  8. Physical Exam • Gen: mildly lethargic but easily arousable • Head: atraumatic; no nuchal rigidity, no bulging fontanelle • Eyes: no scleral icterus, PERRL, + red reflex • ENT: normal TM’s • Neck: supple, trachea midline, no masses • CVS: RRR, no murmurs • Pulm: no resp distress, decreased BS in L base • Skin: mild jaundice • GU: circumcised, testes descended • Neuro: poor suck reflex

  9. Physical Exam SUMMARY • Normal vital signs • Lethargic • Jaundice • Decreased breath sounds at bases (L > R)

  10. Labs • CBC • Hemoglobin – 20.6; Hematocrit – 60.6 • WBC 12.5 Platelets – 376 • CMP: • Na – 140 K – 9.5 (moderately hemolyzed) • Cl – 105 CO2 – 26, • BUN -11 Cr – 0.1 • glucose -77 Bilirubin - 18.7 • AST - 113 ALT - 18 • UA: RBC 0-2, WBC 3-5, Bact +4; glucose neg, pH -5 • T&S: A positive • Reticulocyte count: 0.6 • Coombs: negative

  11. Clinical Course • While awaiting diagnostic studies… Mom encouraged to breast feed • Pt latches – feeds for 3-5 minutes • Desat’s to 80’s • + grunting, +tachypnea, +abdominal retractions • Stablized with blow-by O2

  12. Summary • 6 day old with poor feeding and subjective difficult breathing • Initial normal vital signshowever developed respiratory distress in the ED • Lethargic, jaundice, abnormal lung exam • +Bilirubin, +AST

  13. Diagnosis • What additional test will make the diagnosis?

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