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Administered by: Unknown Purchased by: Unknown
Life Threatening? No
Write-up: 7/13/06: WELL CHILD VISIT. PAST WEEK SPITTY & GAGGY. NO VOMITING, NON BILIOUS, NON BLOODY. STOOLS GREEN JELLY LIKE WITH BLOOD STREAKS, NO FEVER, FEEDING WELL. DX: APPEARS TO BE GERD POSSIBLY WITH VIRAL ENTERITIS OR BREAT MILK COLITIS. PLAN: CBC & STOOL O AND P. HOLD VACCINES UNTIL LAB RESULTS 7/20/06: NO RECURRENCE OF BLOOD IN STOOL. OK FOR IMMS. 2M IMMS ADMIN. 9/14/06: 3M WELL CHILD VISIT. BORN W/ASSYMETRIC FACES SYNDROME. NO GROWTH CONCERNS. 4M IMMS ADMIN. 10/25/06: MOC CALLED STATING BABY GAGS AND SPITTING AFTER FEEDING. TRIED ZANTAC IN PAST WITHOUT RELIEF SO STOPPED. LAST VOID IN AM. 10/26/06, 10:15AM: FOC STATES CHILD VOMITING 4X DAY FOR PAST 2 DAYS MOSTLY AFTER BREASTFEEDING FORMULA. BROUGHT CHILD INTO ED. 2 DAYS AGO HAD X1 LARGE STOOL. INTERMITTENT FUSSINESS. AM X 1 BLOODY STOOL. NO FEVER OR URI SXS. DX: INTUSSUSCEPTION, INCOMPLETE REDUCTION BY AIR ENEMA. PLAN: ADMIT OR FOR INTUSSUSCEPTION REDUCTION PROCEDURE: RQL LIMITED LAPAROTOMY W/ILEOCOLIC INSTUSSUSCEPTION REDUCTION. APPENDECTOMY. NO COMPLICATIONS. DISCHARGED. 11/16/06: 6M WELL CHILD VISIT. HAD INTUSSUCEPTION, BUT DOING WELL. EATING SOLIDS, NO CHRONIC DIARRHEA OR CONSTIPATION. IMMS ADMIN, BUT ROTAVIRUS HELD. 12/12/06 Received medical records from hospital which reveal patient presented to ER s/p 36 hours of vomiting, fussiness & then 1 bloody diaper on 10/26/06. Air enema revealed incomplete reduction of ileocolic IS which was initially present at the sigmoid level & reduced to the hepatic flexure. Taken to OR & findings revealed distal ileum & appendix intussuscepted within right colon extending to mid transverse level which was reduced w/o difficulty & appendix removed. D/C to home on 10/28/06. Final DX: Intussusception, surgically reduced.
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