Antibiotics-EchocardiogramYou request the echocardiogram and are told this will be carried out in the morning – you will know what the cause of the murmur is then. He gets worse over the course of your shift, becoming more tachypnoeic with desaturations.
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 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
The baby has now had an echocardiogram. This showed a normal heart, but with a large patent ductus arteriosus, shunting left to right. The consultant wonders why diuretics were not started with fairly clear signs of heart failure. She starts frusemide and spironolactone, and ibuprofen to help close the ductus. She is also concerned about infection and restarts antibiotics after cultures are taken. 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. 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. He is now off all medication apart from vitamins. His parents are keen to get him home as soon as possible.
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.
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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