Case Study

Case study 5
Due May 8th by 1 am
Points 50
This is the final case study for the course
Pediatric visit:
Reason for Consult: Initial assessment (25yo multip with h/o failed BFing now 4yo, c/o bldy, painful L nipple so not feeding on that side. 5d/o term male with Coombs + ABO incompatibility s/p phototx 3/8-3/10, up 95g/2days, above birth weight (abw), BFing one breast and receiving 3oz formula p qfeed. H/O MI supps) up to 60mls prior to d/c.

OB Status Recent pregnancy
Smoking Status Never Smoker
BSA 1.93 m²

O: MOB nipples evert, + open abraded wounds at tips, breasts mildly engorged.
Assisted with deep latch, L breast with nipple shield (20mm), football hold. MOB reported discomfort for 1st minute of feed, then was able to tolerate and feed 10″ at breast. Breasts significantly softer after feed. Baby sustained and fed vigorously, + audible swallows 1:1
General: Appears uncomfortable with physical exam

A/P: Encouraged MOB to breastfeed as tolerated, with nipple shield, draining first breast first.
Encouraged MOB to gradually over next few days, eliminate 1-4 pumping sessions/d (QOfeed) and pump to comfort only, to avoid engorgement but with goal of d/c’ing pumping completely.
OK to replace breastfeed with bottle feed of ebm if unable to tolerate latch. Otherwise, plan to exclusively breastfeed until next weight (wt) check.
Encouraged MOB to keep nipples dry and clean.
At risk for mastitis, with oversupply and abraded cracked nipples.
Close lactation support to monitor nipples, engorgement and wt gain.

History-Taking-What are your top 3 questions for this patient?
o Pertinent to Case Study Scenario
o Questions are focused-leading to your top 3 differentials – be sure to read the entire case study. (hint: There is a section pertaining to COVID-19)
o What are some questions you would ask related to the clinical presentation? Why?
o What history data should you collect from this pt in order to narrow your diff? Why?
What is the significance of a LATCH score? 10

First Urgent GYN visit:
S: 7d old baby has hx difficulty with breastfeeding. First time breastfeeding MOB (breastfed 1st baby x15d only, then stopped 2/2 “postpartum depression”). MOB has been breastfeeding on R breast only, with 20mm nipple shield, and double pumping with a consumer electric breast pump Q3hrs and yields 8oz (expressed breast milk) ebm. She feeds baby 2oz ebm by bottle, Q3hrs?

EB is a 25 y.o. female who presents complaining of fever and intense breast pain. Fever since last night, associated with onset of pain and feeling of “balls” in her breasts, bilaterally. Has not latched baby on since last night but has pumped and given bottles of pumped milk. Denies using formula since discharge from hospital.
Had LC visit two weeks ago, see discharge notes. No mention of abnormal anatomy of baby. Has been using nipple shield – 20mm
Baby is two weeks old s/p VBAC without complications.
No complaints of ongoing pain other than breast pain. Reports that mood is good despite these symptoms.
Denies cough/respiratory sxs. Said she had a mild throat pain that started today
Has taken no NSAIDs, no ill contacts

Patient Active Problem List
Diagnosis
• Screening for malignant neoplasm of cervix
• Hx of postpartum depression, currently pregnant
• Maternal varicella, non-immune

EXAM:
Visit Vitals
LMP 06/12/2019 (Approximate)
OB Status Recent pregnancy
Smoking Status Never Smoker

Overall well appearing, non-toxic.
Breast exam:
Breast engorged bilaterally. Nipples cracked bilaterally, some scabbing bilaterally.
No erythema.
No discreet clogged ducts appreciated.
2. Physical Examination-Focused Exam
o What physical examination findings would CONFIRM or RULE OUT your diagnosis? List 3 with your explanation as to how you confirmed or ruled out your differentials
o What POS/NEG. Physical Examination data would you find?
o Include ALL systems needed to complete your assessment of your patient
o Pertinent positive & negatives emphasized
Are any exam items missing in this case so far?

10
Impression and Plan:
Mastitis related to breastfeeding
Reviewed/updated problem list
Unable to refer to LC d/t reduced schedules related to COVID 19 precautions.
Milk culture so abx can be changed prn without another in person visit.
Diclox #40, acetaminophen rx’ed.
Latched baby with football hold successfully with decreased pain. Reviewed importance of good latch and demonstrated. MOB needs to bring baby closer to breast.
New shields will be available in postpartum today.

Discussed coronavirus precautions with patient including hand washing, staying home as much as possible, good sleep habits and healthy eating. Reviewed symptoms including cough, fever, shortness of breath, pain or pressure in chest – if any symptoms advised patient to call L&D.

I spent 20 minutes counseling this patient about the above topics.

Visit 3/20:
Spoke to patient’s Aunt Rosa who reports baby is not latching, they are concerned and need more help. Scheduled for this afternoon with CNM Lance after doing a phone consult.
Per susceptibilities report from lab, Staph Aureus in breastmilk. Changed abx from diclox to clinda, patient informed and will pick up today.

1. S) Add on today for follow up for mastitis. Was started on Diflox for mastitis. Reports taking abx x 2 d Cultures resulted. Resistant to Diflox

Seen by lactation on 3/14. Nipple shield for damaged nipple, over supply, instructed to pump to comfort not to empty breast. Mastitis precautions reviewed
Seen by provider 3/18 for mastitis. Does not have nipple shield and reluctant to latch on R breast. Deep latch observed in football hold on L breast. Latch pain free

O: Breasts/Nipples
R breast: nipple scabbed but healing
L breast: engorged, warm. No red streaks. No palpable abscess. Nipple cracked, abraded, yellow exudate

A/P: 25 y.o. G2P2002, 2 weeks s/p VBAC
Consult with lactation:
Septra DS BID x 10d sent
Abscess precautions reviewed
Follow up for Next scheduled follow-up: Pediatrics, K6, 3/22/20 at 3pm.

Visit Vitals
BP 119/80
Pulse 92
Temp 36.7 °C (98.1 °F)
Wt 81 kg (178 lb 9.6 oz)
LMP 06/12/2019 (Approximate)
BMI 29.72 kg/m²
3. Screening and Diagnostic Testing with Rationale-“What are you looking for…?”
o What tests would you order today to confirm or narrow your suspected diff dx, & why? 5
4. Formulating the 3 Most Likely Differential Diagnosis with Rationale
o #1-being the most likely diagnosis
o What are some probable causes of the presenting symptoms? Include physical,
environment, organisms, lifestyle, etc.
5
5. Health Maintenance Specific to Patient
o Appropriate to age, gender, and risk factors
o Health maintenance recommendations/precautions you would consider for this patient? 5

Follow-up, High-Risk Newborn clinic visit 3/22:

Patient presents with aunt – now 2+ weeks postpartum, today is day 3 of new antibiotic. Was switched from diclox to clindamycin
Pus noted in milk with pumping
No fevers since Friday
Fever noted initially, denies cough or SOB, no ill contacts
Pain is reduced, no skin peeling or pus noted externally
Using nipple shield to feed at breast then pumping bilaterally – yield 4 oz on L, 2 ox on R
Feeding ebm to infant by bottle, unsure nipple size; infant taking up to 4 oz after feeds at breast
Output is above nl
Weight gain 130 g/2 d

Hospital Discharge Lactation Notes:
Maternal Lactation Information
Has mother breastfed before?: failed attempt

Exclusive Pump and Bottle Feed: No
WIC Program: Yes

Breast/ Nipples
Breasts/Nipples (WDL): (Breasts full with mature-appearing milk on hand expression. Nipples evert bilat with abrasions at tips L>R,) L nipple tip denuded.

Intervention: Breast pump (Using manual pump from birth admission for 60mls EBM. Also has personal electric pump from her cousin, not used.)
Breastfeeding Status: Yes

Infant Assessment
Infant State: Sleeping
Oral Anatomy (WDL): Within Defined Limits

Supplemental Feeds: Yes
Type of Supplement: Expressed breast milk, Formula
Frequency of Feeds: every feed
Volume: up to 3oz
Number of Voids in Last 24 Hours: 4
Number of Stools in Last 24 Hours: (yellow)

Latch Documentation
Latch: Grasps breast, tongue down, lips flanged, rhythmic sucking
Audible Swallowing: Spontaneous and intermittent (24 hours old)
Comfort (Breast/Nipple): Filling, red/small blisters/bruises, mild/moderate discomfort
Hold (Positioning): Minimal assist, teach one side, mother does other, staff holds
LATCH Score: 8

Other OB Lactation Tools
Lactation Tools: Nipple shields (I introduced a 20mm shield for L breast only)

Other OB Lactation Documentation
Additional Problem Noted: MOB only feeding on R breast d/t concerns about bloody L nipple and exquisite pain, pumping d/t very full breasts. Maternal concerns baby not satisfied with BFing, and baby receiving large volume bottle-feeds. Maternal c/o sore axillary tissue.

-I introduced a 20mm shield for L breast only. Disc temporary nature of shield use. Improved maternal comfort per MOB.
-I reassured re axillary breast tissue soreness/ fullness. Advised cold compress prn and expect improvement over next 3-5days.
-Advised to avoid pumping/bottles. Okay to use hand expression just until more comfortable for full, uncomfortable breasts btwn feeds. Only pump if not latching at all. Then give up to 60mls EBM by bottle with slow flow nipple – 1.2 oz at a time, paced with ret to breast between.
Advised to excl BF at early cues at least q2-3hrs waking baby PRN. Keep baby stimulated at the breast.
Disc meaning and importance of unrestricted BFs, offering second side after baby finishes first.
Enc to use position/latch techniques demonstrated today for deepest latch and optimal milk transfer.
Reviewed close positioning with direct approach leading with chin and nipple-to-nose for wide gape and deep latch.
Advised to release suction and relatch deeper for nipple pain persisting beyond initial latch.
Advised application of EBM and air dry after feeds. Disc use of lanolin cream as desired.
Enc attention to hand hygiene, disc signs and symptoms of infection and when to seek care.
Reviewed AAP/WHO recs for BFing duration/exclusivity.
Reviewed benefits of BFing for baby and mother.
HGH BFing warmline # given.
RTC in 2days for wt check and f/u lactation consult, test weight recommended at next visit
6. Evidence-Based Plan of Care
o Specific treatment options are defined including EBP guidelines
o Accurate first-line pharmacotherapy, drug, dose and rationale
o What are some non-pharmacological treatment options that you would recommend
o What is your follow-up plan? Education specific? At what point is a referral indicated?
o On the follow-up visit, what alarming symptoms would prompt you to refer
o Given the initiation of COVID-19 mentioned above, how would you include integrate precautions and recommendations?
o What if mom was COVID-19 positive?
o In considering her developmental stage and family issues, what are some relevant issues that you would address in your plan of care for this patient?
o Further assessment, referrals, medications, and treatment are delineated, as appropriate 15
TOTAL 50