This document presents the case of a 3 month old male infant referred to the Children's Emergency Room with complaints of vomiting since birth, swelling on the left forearm, fever, watery stools, and coughing/catarrh. On examination, the infant was found to be small for age but otherwise healthy. Initial workup revealed malaria parasites. The infant's condition improved with treatment, and further tests found no abnormalities. He was ultimately diagnosed with gastroesophageal reflux disease and discharged upon gaining weight and reducing vomiting with feeding adjustments. Follow up visits showed continued improvement.

1. GERD CASE MANAGEMENT
PRESENTATION
BY
DR EFFIOM, VICTOR E.
HO
Pediatrics

2. BIODATA
 C.C.G
 3 Months
 Male
 No. 4 Asari Iso Layout Street, Calabar.
 Hails from Imo state, Igbo Tribe.
 Christian
 Admission: Via CHER
 Informant: Mother (Reliable)

3. History
 PC:
-Vomiting since birth
-Swelling on the left Forearm x 1/52
-Fever x 4/7
-Passage of watery stools X 3/7
-Cough and catarrh x 1/7

4. History Of Presenting Complaint (A).
 Vomiting was noted since 1st day of life.
 Non-projectile, non-forceful, persistent, post-prandial, non-
bilious, usually from immediately after meals to 30 mins.
post feeding.
 Quantity depended on quantity of breast milk intake. There
was no associated history of loss of appetite as child was
always eager to suckle at breast.
 Color is that of breast milk, not blood stained and not
offensive.
 Episodes of vomiting mostly averaged 10x per day. Had
vomited 6x already prior to presentation at CHER.
 Nil abdominal swelling.

5. HISTORY OF PRESENTING COMPLAINT
 Swelling on left forearm was initially small in size measuring
about the size of a peanut.
 Swelling had progressively enlarged but did not discharge any
purulent effluents.
 No differential warmth. Mild tenderness. Not fixed to underlying
tissue.
 No preceding trauma or injury

6.  Fever started 4/7 prior to presentation at
CHER.
 Was high-grade and continuous.
 Nil convulsions, nil excessive crying or crying
during micturition
 Nil tugging of the ears
 Subsides with administration of tabs PCM and
tepid sponging.

7. HISTORY OF PRESENTING COMPLAINT
CONTD.
 Passage of watery stools noticed 3/7 days prior
to presentation
 Sudden onset
 Occurred on an average almost 8x in a day
 Non-mucoid, not blood stained, non-copious.
 no curling up or crying to show abdominal pain

8.  Cough: Non-paroxysmal.
 Nil difficulty in breathing, nil fast breathing,
 Had no variation with time of the day (Not worse at night)
 Occasionally associated with post prandial vomiting.
 Nil hx. of force feeding
 No known aggravating or relieving factors.
 no bluish discoloration of lips and extremities.

9.  For the above set of complaints, baby and mother
presented at the CHER for expert management.
PAST MEDICAL HX.
 Baby was admitted during neonatal period on account
of jaundice and was treated with phototherapy.

10. Prenatal, Natal and Post Natal History.
 Spontaneous conception & desired
 Received 2 doses of TT & IPTp.
 Was placed on Haematinics and vitamin C through out
duration of pregnancy.

11.  Investigations done for RVS, HBsAg, HCV were all
negative.
 Not a known HEADS0
 Delivery via Elective Caesarean section
 Outcome live male Neonate, Wt: 3.2kg.
 Baby cried immediately after birth
 Exclusive breastfeeding/immunised for age.
 Puerperium was uneventful.

12. DIETARY AND NUTRITIONAL
HISTORY.
 Predominant breastfeeding x 2months
 Currently supplementing by adding guinea corn, millet
and NAN 3x daily. Recently introduced another milk
2/52 with no improvement.

13. Immunization Hx.
 Has been immunized for age
Developmental History:
- No Neck control, sustained grasp of objects.

14. FAMILY AND SOCIAL HISTORY
• Patient is third in a family of 3, (2 males and 1
female, all alive and well).
• Both parents are alive and well.
• Mother is a 23 year old graduate, unemployed.
• Father is a ? old plumber, self employed with
secondary level of education.

15. SUMMARY
I have presented the case of C.C.G a 3 months old infant
who presented at the Children emergency clinic with
complaints of Vomiting since birth, Swelling on the left
Forearm x 1/52, Fever x 4/7, Passage of watery stools X 3/7
and Cough and catarrh x 1/7.

16.  PHYSICAL EXAMINATION
o A conscious, Small for age, afebrile (36.70C), not pale,
anicteric, acyanosed, not dehydrated, not in respiratory
distress, no peripheral Lymphadenopathy, nil pedal edema,
no dysmorphic features.
o Anthropometry
*OFC: 39cm (Adequate)
*Weight: 3.6kg (~60th pecentile)
*Length: 54cm (75th percentile)
 .

17. o ABD: full, moved with respiration, soft.
Liver was palpated about 2cm below the costal
margin, firm, smooth and non-tender.
 RESPIRATORY SYSTEM
o RR – 44 cpm,
o Vesicular breath sounds, nil crepitations.

18.  CARDIOVASCULAR SYSTEM
o PR - 140 b.p.m, regular, normal volume.
o BP – no appropriate cuff.
o heart sounds: S1, S2 only. No murmurs
MSS: Mass on left forearm measuring 2.5cm by 2cm. Firm, no
differential warmth.
CNS: Conscious and alert, AF: flat and normotensive, no
neck control, nil signs of meningeal irritation, normal tone in
all limbs.

19. Working Diagnosis (CHER)
 1. Partial Intestinal obstruction ? Cause r/o Congenital
hypertrophic pyloric Stenosis
 2. Sepsis (furunculosis, diarrheal disease + URTI)

20. Treatment
①Admitted to CHER.
②Carry out following investigations; MP,
Abdominal USS, FBC, Barium meal and follow
through, E,U,Cr.

21.  ORS Plan A 50-100/mls per loose stool.
 Started on IV Ampiclox 180mg every 6hrs till reviewed
 Tabs Zinc 10mg daily x 2/52
 Vitamin A 100,000IU dly x 2days, then 1 dose 2weeks
later.

22. Investigations:
 Retrieved on 2nd day of admission.
 FBC
a. PCV: 42%
b. WBC: 7.8 X 109/L
c. Neutrophils = 28%
d. Eosinophil = 1%
e. Lymphocyte = 71%
f. Monocytes = 0%
 MP
Trophozoites of P. Falciparum + seen.

23.  E/U/Cr
1. Urea: 3.0 mmol/l
2. Na+: 137mmol/l
3. K+: 3.6 mmol/l
4. HCO3: 25mmol/l
5. Cl--: 98mmol/l
6. Creatinine: 102umol/l.

24.  On the 4th day of admission, patient was no more passing
watery stools. Has had 6 episodes of vomiting over past 24
hours.
 Vital signs had been stable since admission and child was
sucking well at breast.
 Swelling over the anterolateral part of the L. forearm had
become fluctuant in consistency.
 Plan was initiated to
• Do an Incision and drainage for abscess. Consult was sent
to the PSU.
• Introduction of syrup P-Alaxin 7.5mls dly x 3/7 following MP
result.
• Continue breastfeeding and present medications (Ampiclox,
zinc)

25. On the 8th day of admission,
ABD USS: no abnormality detected.
Barium swallow meal and follow through: Normal.
Current weight: 3.7kg
::: A diagnosis of Gastroesophageal Reflux Disease

26. Plan
 Counseling the mother
 Commencement of cereal and infant formula
 Put patient to lie prone
 Alternate day weighing
 Keep feeding/vomitus chart
 Small frequent feeds (cereal and infant formula) @
30mls 2hrly x 24hrs and then further reduced to 10mls
hourly.

27.  On the 9th day of admission, regurgitation had reduced
in frequency since the commencement of NAN 1 and
patient is also lying prone.
 Weight on day 9 of admission was 3.9kg
 Abscess had reduced drastically in size.
 Vital signs remained stable.
 Was to complete 7 days of IV Ampiclox.

28.  Patient continued to improve clinically.
 Vomiting little quantity.
 Mother admits to child’s improved clinical state
and requests discharge home.
 Weight was 4.05kg
 Patient was discharged home on mothers
request.

29.  Continue oral tabs zinc 10mg daily.
 Feed 10mls hourly.
 Nurse prone and keep upright for 30mins after feeding.
 See in clinic in 3/7.

30. FOLLOW UP VISIT 1.
 Age: 4 months 5 days.
 Weight: 4.5kg
 RR: 40cpm
 Patient is gaining weight (gained 0.45kg in 3 days)
 Tolerating frisco rice with NAN 1
 Regurgitation reducing in volume and frequency.
 Neck control is improving.
 Mother happy with infant’s improvement.
 Mother advised to continue small, frequent feeds and keep
upright for at least 30mins after feeding. Infant to lie prone.
 To see in clinic in 2/52.

31. Follow up visit 2
 Age: 4 months
 Wgt was 5kg. (83% of EWA)
 OFC=41cm
 Length=60cm
 Chest is clear.
 Doing well.
 Vomiting had reduced in frequency and volume.
 Had attained neck control.
 Nil fresh complaints.

32.  Continue with feeding as prescribed
 See in 1/12.

33. Thank you…