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* nbme 3, please answer
 #843365  
  sandhu123 - 08/10/17 16:08
 
  You are called to the neonatal unit of the hospital to evaluate a male neonate who is not breastfeeding well. The neonate was born 12 hours ago to a 27-year-old woman. He is the mother's
first child. He was born at term via uncomplicated vaginal delivery; he was vigorous at the time
of delivery. The mother received appropriate prenatal care throughout her pregnancy. She says
that the neonate appears hungry, but soon after he latches onto the breast he gags and becomes
uninterested in feeding. Vital signs now are temperature 37.0C (98.6F), pulse 150/min, and
respirations 40/min. On physical examination, the neonate is alert and active. Lungs are clear.
Chest and abdomen are normal. Anus is patent. The neonate has passed only a small smear of
stool since birth.
On day 2 of life, the neonate continues to have problems with feeding. On physical examination
now, he appears alert and vigorous. Abdominal girth is increased 3 cm (1.2 in) since birth. The
abdomen is distended, but it remains soft to palpation. The neonate has not passed any stool
today. A nasogastric tube is inserted and less than 10 mL of clear, nonbilious secretions with
small flecks of brown blood are disclosed. Which of the following is the most appropriate next
step?
A) Administer ranitidine
B) Administer sucralfate therapy
C) Do lower gastrointestinal barium study
D) Obtain plain x-ray of the abdomen
E) Order upper endoscopy
 
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* Re:nbme 3, please answer
#3345506
  lamonti - 08/10/17 19:51
 
  C) Do lower gastrointestinal barium study  
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* Re:nbme 3, please answer
#3345516
  frontallobe - 08/11/17 00:54
 
  You dont have the correct answer??  
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* Re:nbme 3, please answer
#3345540
  sandhu123 - 08/11/17 11:21
 
  nope, I think the anser key is not accurate, would like to know people's input. Why not give Ranitidine or PPI before doing something more invasive later ? Gastric ulcer seems common in newborn :(  
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* Re:nbme 3, please answer
#3345542
  lamonti - 08/11/17 11:47
 
  Sandhu, Gastric ulcers happen in neonates in intensive care unit. I don't think abdominal distension is a feature of gastric ulcer. Abdomen is soft. I believe this is a case of Hirschsprung's disease. Any other input is welcomed.

What form of NBME is this?
 
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* Re:nbme 3, please answer
#3345549
  abatson - 08/11/17 12:58
 
  Lamonti, I agree with your diagnosis but why not plain abdominal xrays first?
Are you going for lower GI Study because the NG Lavage was suggestive of a lower GI Cause?
 
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* Re:nbme 3, please answer
#3345567
  frontallobe - 08/11/17 16:36
 
  A or b seem less likely as patient is only 12hrs old and unlikelt to be ulcer/reflux. I agree with Lamonti too but I think Xray would be done before jumping to a barium study.  
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* Re:nbme 3, please answer
#3345570
  dreamz4usmle - 08/11/17 17:24
 
  i would go with choice D too...its a case of failure to pass meconium either meconium plugs or meconium ileus...it would go more in favor of meconium plug as the q stem does not specify anything about CF...so hirshprung's can be the probable diagnosis.

In case of failure to pass meconium,the first study to go for is Abd xray to look for bowel gas pattern.
based on that,further diagnostic and therapeutic interventions can be planned.

Thats my understanding.


 
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