Ezekiel T.

Rosimo
4MD

MCU – College of Medicine

PEDIATRIC CLERKSHIP – August 2, 2021 Activity

Informant: Mother Reliability: 90%

GENERAL DATA
M.C. G., male, 3 days old, Filipino, Roman Catholic, delivered in a lying clinic via
NSVD, cephalic presentation , 38 wks AOG , with a birthweight 2,600 gms AGA, APGAR
score of 8,9 , EINC done. Patient was able to passed out stools and urine within 24 hours and
so was discharged after 1 day.

Chief complaint: vomiting

History of Present Illness:

Patient was born to a 35-year-old, Gravida 3 Para 3 (2101) mother, 38 wks AOG. The
patient was apparently well until 1day PTA, patient coughing spells. It was noted, the
episodes would occur whenever feedings with mother’s breast milk were given but less severe
whenever given slowly thru dropper. There were also episodes of regurgitation and fussiness
when fed. The baby would appear well and content when feeds were stopped.
Few hours PTA, patient was noted to be vomiting after feeding and coughing. Mother
still was giving the stored breastmilk thru dropper. However, the last feeding session, mother
noted some circumoral cyanosis which prompted mother to bring patient to MCU Hospital
and subsequently admitted.

MATERNAL HISTORY:
FIRST TRIMESTER:
The mother experienced the usual signs and symptoms of early pregnancy such as urinary
frequency, breast tenderness, easy fatigability, nausea and vomiting. On the 1st month of
missed period, self-pregnancy test was done, which revealed positive result. On the same
month, she consulted a private physician where the following diagnostic tests such as CBC,
Hepatitis B antigen screening, VDRL/RPR, and fasting blood sugar which revealed normal
results. Ultrasound done revealed a single, live, intrauterine pregnancy compatible to 11
weeks 5 days age of gestation by average crown rump length with good cardiac and somatic
activities. She was given multivitamins 1 tablet per day and folic acid 1 tablet once a day
which she took irregularly. She denies any history of accidents, trauma, illnesses or exposure
to radiation and toxic chemicals.

SECOND TRIMESTER
 Quickening was felt on 5th month of pregnancy (November 2019). She had regular prenatal
checkup and regular intake of multivitamins, calcium and Ferrous Sulfate. Complete blood
count, urinalysis, HBsAg, Oral Glucose Tolerance test, fasting blood sugar and urinalysis
were all normal. Other had a history of cough and fever. Her Obstetrician gave her antibiotic
of 7 days duration. She denies any history of accidents, trauma, or any exposure to radiation
or toxic chemicals.

THIRD TRIMESTER
Subsequent prenatal checkup as well as intake multivitamins, calcium and ferrous Sulfate
were regular, Abdominal ultrasound was done few weeks prior to EDC, which revealed a
single, live, intrauterine pregnancy with good cardiac and somatic activities, Fetus in cephalic
presentation, antero-fundal grade 3 placenta. Biophysical score was indicative of good fetal
well-being.

BIRTH OUTCOME:
The patient is a Live, fullterm, single, male, delivered via NSVD, BW of 2,600 grams ,
AGA, APGAR score 8,9 in a Lying -in clinic. Discharge after one day stay without any
problem noted post -natally.

FAMILY HISTORY:
Paternal Grandfather: (+) DM and Hyptension
Elder Sibling (Brother): (+) asthma

SOCIO-ECONOMIC HISTORY:
Father is computer analyst in a private company, while mother is a secretary in a textile
company. The family lives in a rented two room apartment which is near a textile company
where textiles are treated with chemical dye. Garbage collected regularly. Drinking water is
being bought in a water filtering station.

FEEDING HISTORY:
Breastfeeding since birth direct feeding thru the breast then later dropper feeding of stored
breastmilk

IMMUNIZATION:
BCG and Hepatitis B at birth

PHYSICAL EXAMINATION:
General survey: irritable, conscious, pinkish, in respiratory distress
Vital signs: RR: 65 breaths/ min CAR: 130beats/ min
Temp: 36.7 degrees centigrade
Anthropometric measurements:
BW: 2,600 gms Birth length: 49 cm
HC: 34 cm CC: 33 cm
Pertinent findings:
 HEENT: Open, flat, soft anterior and posterior fontanels, positive ROR, bilateral, pink
palpebral conjunctiva, white sclera, patent ear canals, with nasal flaring and grunting, moist
lips and moist buccal mucosa
CHEST/LUNGS: Symmetrical chest expansion, with subcostal and intercostal retractions,
course rales on both lung fields
HEART: Adynamic precordium, tachycardic, regular rhythm, no murmur
ABDOMEN: Slightly globular, soft, no mass, no organomegaly, with bowel sounds,
umbilical cord has 2 arteries and 1 vein
SPINE: Straight, midline, no tufts of hair, no mass
GENITALIA: Normal looking male external genitalia, no urine output yet
EXTREMITIES: No gross deformities, full and equal pulses, CRT <2 seconds
SKIN: Cyanotic, prominent visible veins , no active dermatoses
REFLEXES: Positive Babinski, Moro and Rooting Reflexes

GUIDE QUESTIONS:
1. What are the salient features of the case?

- Patient presented with episodes of coughing, cyanosis (specifically in the mouth) and was in
respiratory-distress.
- Feeding exacerbates the symptoms manifested by the patient.
- Course rales on both lung fields upon auscultation.
- Subcostal and intercostal retractions.
- RR of 65 breaths/min

2. Give at least three differential diagnosis or diseases to consider. Justify

these diseases then reasons for ruling in and ruling out the specific disease.

Differential Diagnosis Rule In Rule Out

Aspiration pneumonitis
Pharyngeal
pseudodiverticulum
Tracheal agenesis
-Rales -Fever or hypothermia
-Tachypnea -Decreased breath sounds
-Respiratory distress
-Vomitus
-Tachypnea -Pneumomediastinum
-Vomitus
-Respiratory distress
-Respiratory distress -Polyhydramnios
-Inability to intubate -Inaudible cry

3. What is your impression? Why?

- The case strongly suggests Tracheoesophageal fistula in a live birth, full term infant. This is
so because of the symptoms manifested like vomiting, cyanotic, coughing and in respiratory
distress plus exacerbated by feeding.

4. Give the pathophysiology/pathogenesis of the disease of the patient.

 - The esophagus and trachea both develop from the primitive foregut. In a 4-to 6-week-old
embryo, the caudal part of the foregut forms a ventral diverticulum that evolves into the
trachea. The longitudinal tracheoesophageal fold fuses to form a septum that divides the
foregut into a ventral laryngotracheal tube and a dorsal esophagus. The posterior deviation of
the tracheoesophageal septum causes incomplete separation of the esophagus from the
laryngotracheal tube and results in a TEF.

5. What are your diagnostic procedures for your patient? Justify for each.

a) Perinatal radiograph: examine for absence of the infant stomach bubble and maternal
polyhydramnios.
b) Plain radiograph: Examine a possible coiled feeding tube in the esophageal pouch and/or an
air-distended stomach.
c) Esophagogram with contrast medium: for demonstration of an isolated TEF (H type)
d) Endoscopy with methylene blue dye: examine possible defects in the esophagus during forced
inspiration.

6. What are your pharmacologic and non-pharmacologic plans? Justify.

Non-pharma:
a) Pre-operative proximal pouch decompression – to prevent aspiration of secretions
b) Prone positioning – Minimize movement of gastric secretions into distal fistula.
c) Esophageal suctioning – Minimize aspiration from a blind pouch.
d) Surgical ligation and primary end to end anastomosis of the esophagus via right sided
thoracotomy
e) Thoracoscopic surgical repair
Pharma:
- Antibiotic use – empirical drugs like Ampicillin and Amikacin for anticipated mix of gram
positive and gram-negative bacteria.

7. What is your advice to the parents once patient is discharge?

- Assurance to parents that during the first 5 years of life are difficult but resolves after and
child will continue to have normal life.
- Surgical complication would include anastomotic leaks, refistulization and anastomotic
stricture