Steroids -AntibioticsDom Barton is restarted on Benzylpenicillin and Gentamicin after blood cultures are taken. However, as expected, he gets worse over the course of your shift, becoming more tachypnoeic with desaturations. Antibiotics are likely to take some time to work.
You decide to reexamine him: Respiratory: RR 65/min, moderate recession, equal chest movement. Inspiratory crackles in the chest. SaO2 88% in 75% oxygen. Cardiovascular: HR 165/min, capillary refill time 4 seconds. Bounding pulses and easy to feel femoral arteries. BP 85/30, Heart sounds normal, with an unchanged systolic murmur still heard under the left clavicle. You decide to reintubate Dominic and allow the ventilator to take over the work of his breathing. After this, his is much better oxygenated and better perfused. His heart rate settles. His parents are very worried about the developments and want to know what you are doing to find out what is wrong with him. You explain that the most serious problem he may have is infection, and you are addressing this. Tests will show if this is the case. You take some blood to check the electrolytes and for signs of infection at the end of your shift.
The following day, at the consultant ward round the results are reviewed: Hb 132 g/L Wcc 10.3 x 109/L Plats 395 x 109/L Urea 2.2 mmol/L Na 139 mmol/L K 4.5 mmol/L Creat 41 micromol/L Because of the chest radiograph, the consultant wonders why diuretics were not started with fairly clear signs of heart failure overnight. She starts frusemide and spironolactone, and requests an echocardiogram. She is pleased that someone thought about infection. Later that morning the echocardiogram shows a normal heart, but with a large patent ductus arteriosus, shunting left to right. With these medicines he improves and is ready to come off the ventilator after another two days ventilation.
You next meet baby Dominic Barton when he is three weeks old; he has done well and is preparing to go home and you have been asked to do his discharge check. His nurse notes that he has an inspiratory breathing noise from time to time. She also thinks he has become a little jaundiced. Looking through the notes you see that his blood cultures were sterile. You also note that his skin swabs have shown MRSA. Since you last saw him, he has also had a follow-up echocardiogram showing that the ductus has closed. His diuretics were stopped after this. He is now feeding well independently and his mother has established him on formula milk. She was hoping to breast feed him, but the stress of his neonatal course affected her milk production and this has not been sufficient for Dominic. Both parents are very anxious and concerned about taking him home in view of the problems that he has had. They have also looked up some of his treatments on the internet and are concerned that the steroids that he had in the immediate newborn period may have affected his growth and brain development.
Mild jaundice, visible in sclera and on skin. Nappy – yellow urine and slightly pale stool. Weight 1.80 kg. Respiratory: RR 30/min, no recession, equal chest movement. Clear chest. SaO2 98% in air. Stridor when upset. Cardiovascular: HR 135/min, good capillary refill time. Normal femoral arteries. BP 85/40, Heart sounds normal, no murmurs heard. Abdominal: Full, but soft on palpation, liver edge palpable at 2cm below costal margin, no other organs felt. Neurological: Active and alert, moving all limbs. Able to fix eyes on objects. Anterior fontanelle soft. His right leg appears swollen compared to the left, although the perfusion and pulses are normal. You arrange an ultrasound of the leg veins to look for a deep venous thrombosis.
What is the most appropriate action at this stage? A Check bilirubin and discharge if not requiring phototherapy, see in clinic next week. B Check bilirubin (split into conjugated and unconjugated), liver function tests, direct combes test, thyroid function test and urine culture; keep as inpatient until these results are available. C Check bilirubin, then transfer to liver specialist centre |
Map: TAME case 1 - Dominic Barton (Tutorial 1) (320)
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