Downs baby with fever and vomiting

Discussion on management


Summary

4 years and 9 months old diagnosed patient with Down syndrome from Galle admitted to the Teaching hospital Karapitiya complaining of fever and bilious vomiting for one day duration. Fever is not associated with chills, rigors, fits or rashes. Bowel habits and urine output is normal.

On examination child has dimorphic features. Pulse rate is 110bpm, regular and good volume. There is parasternal heaving.Resspiratory rate is 24 cycles per min.She is hypotonic and all reflexes are diminished. Examination of respiratory system and the abdomen reveals no abnormality.

Differential diagnosis


  • Duodenal atresia
  • Annular pancreas
  • Malrotation

This child yesterday presented with bilious vomiting for one time and this is the first time she has passed bile with vomiting in her life time.

This can be due to many reasons.

Simply it can be due to because of after vomiting for several times and then duodenal contents also can be passing with vomitus and then that vomitus can contain bile.

I think this is the most probable cause for having passing bile with vomiting by this time by this child.

But because of this child has been a diagnosed patient to have Down’s syndrome have to exclude the possible causes to having bilious vomiting.

There are congenital causes that lead to bilious vomiting such as

· Duodenal atresia

· Annular pancreas

· Malrotation/Volvulus

· Malrotation/Ladds band

· Ileal atresia

And acquired causes such as

· Intersuccseption

· Gastroenteritis

· Reflux

· Medication

· Toxic ingestion

· Crhons disease

Regarding this child the possibility of having acquired cause is very low

But she may be having one or more of the congenital abnormalities

At the age of one month Ultra Sound Scan has done and it was normal

At the age of 3 months Hida scan has done and it was also normal (When investigations done for prolong jaundice)

After that no other investigations had done so far.

So this time planned to do an upper Gastro Intestinal studies to exclude any congenital abnormalities like duodenal atresia, annular pancreas or malrotation.

On top of this acute medical problem she can be having multiple medical and social problems which need extra care.

As this child can developed sensoneural deafnessrelated to fluid buildup in the inner ear or to structural problems of the ear

regularHearing assessment has to be done to assess her hearing which has not done so far. Because if occur these problems then can affectlanguage and learning skills.

Although the visual assessment has done at the age of 2years and said normal, she is in a risk of developing visual problems likeamblyopia (lazy eye), near- or farsightedness, and an increased risk of cataracts. Regular evaluations by an ophthalmologist are necessary to detect and correct any problems before they affect language and learning skills.

There for I think better to do a visual assessment again

As this child speak out only 2 to 3 words to make simple phrases but not talks constantly in 3 to 4 word sentences which is appropriate for her age, I think better to forward this child to a speech therapist as well.

Because she is almost normal as other children in her age in aspects of doing day today activities I don’t think she needs the help of an occupational therapist or physiotherapist.

Hypothyroidism has excluded at the age of one month. But still there is a possibility to have it. As this child can get intellectual impairment and if there is hypothyroidism is present as well that will cause the condition worse. Hypothyroidism is a condition that can be preventable, therefore I would like to do thyroid function test in this child as well.

Echocardiogram has done twice at the age of one month and one year and find out there is a mild atrio sepatal defect and no need of surgery.

But I would like to do an echocardiogram again to see the progress of the heart defect.

There is a risk of developing childhood Leukemia in this child. There for full blood count and blood picture has to be done and if suspicious have to do a bone marrow biopsy.

This child lives with her parents and grandmother. She was taken to the preschool by her father and taken back by her mother and in the preschool all the teachers are caring about her. Therefore she has good protection always. As her mother is also a housewife it gives additional advantage regarding this matter. Parents have to be educated about the Childs protection because she will not able to protect her self in the future.

Because everyone pays a special attention to this child there is a possibility to develop attention deficit hyperactivity in the other child. Therefore advice parents regarding that matter as well and to keep same love and care to that child as well.

If this child can be attend to a special school that will be beneficial as well.

As such a school is at Pamburana ,Matara parents can be motivated for that as well. But have to consider other factors too like traveling difficulties and the cost.

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