Vomiting and a Rash – OSCE Case

When did this first begin?

“I think about two weeks ago”

When does it occur in relation to feeds?

“About 30 minutes after feeding”

What is in the vomit?

“The undigested food he just ate”

Is the vomit projectile, or more like a dribble?

“It’s just normal vomit really. Probably more like dribble if anything, it’s not projectile.”

Does Chris seem to be in any pain?

“He’s a bit irritable during these episodes, but we don’t think he is in pain”

Can you describe the rash?

“He gets raised patches of swelling all over, they look like hives. And it looks red”

What are you feeding him at the moment?

“He was previously breastfed, but we have recently been giving him some formula instead”

Past medical and surgical history

• Does Chris have any medical problems?

Specifically, ask:

• Does he have a history of breathing difficulties or asthma?

“No, he’s not had any medical problems so far.”

Medication history/allergies

• Does he take any regular medication?

Specifically, ask:

• Does he have any allergies?

“No, no medication and no allergies that we know of.”

Family history

• Is there a family history of breathing difficulties or asthma?
• Is there a family history of allergies?
• Do any other medical problems run in the family?

“His brother gets hayfever and has eczema, but nothing else we know about.”

Social history

• How was your pregnancy with Chris?
• Any problems during the birth?
• How was he delivered?
• Was he born at term?
• Has he had all his vaccinations so far?
• Has he been meeting his developmental milestones?
• Does anyone smoke in the house?
• Have there been any recent changes to his diet?

“The pregnancy was fine and he was a natural delivery at term. Everything seems to be going well apart from this vomiting, he’s had all his vaccines and no issues with development. No-one smokes. I used to just breastfeed him but we’ve been trying some formula over the last couple of weeks.”

Systems review

• Has he had a cough? 
• Any fever/chills? 
• Has he had any diarrhoea? 
• Have you noticed any noisy breathing
• Have you noticed any swelling of the lips, around the eyes, or tongue 

“He’s had some loose stools in the last couple of weeks, but nothing else”

For more information, see the Geeky Medics guide to paediatric history taking.

• Basic observations (vital signs)
• Cardiac examination to assess pulse and general stability
• Respiratory examination to listen for any additional breath sounds that may suggest ongoing acute allergy symptoms
• Abdominal examination to palpate for any abdominal masses or distension and to listen for bowel sounds.

Examination findings

• Observations: SpO2 99% breathing air, BP 100/60 mmHg, HR 100 bpm, RR 22 breaths per minute, temperature 37 ^oC
• Weight 8 kg
• Pulse is regular
• Central and peripheral pulses are palpable
• Vesicular breath sounds on auscultation
• No hoarseness in voice
• No abdominal masses or distention
• Bowel sounds are present and normal

• Urticarial rash

• Skin prick test
• Serum specific IgE

• Abdominal ultrasound
• Abdominal x-ray
• Urinalysis
• Stool culture and sensitivity

• IgE-mediated cow’s milk protein allergy
• Non-IgE mediated cow’s milk protein allergy
• Food intolerance
• Gastrointestinal infection
• Non-gastrointestinal infection (e.g. urinary tract infection)
• Intussusception

IgE-mediated cow’s milk protein allergy (CMPA)

Allergen avoidance. In most cases, avoiding consumption of the allergen should be sufficient. However, depending on the severity and sensitivity of the allergy, patients may also need to take measures to avoid cross-contamination when preparing food and ensure any equipment used to prepare the allergen is thoroughly cleaned between uses.

• Medication such as corticosteroids and antihistamines to help with symptom relief
• Adrenaline autoinjector prescription if there is thought to be a risk of anaphylaxis
• Allergen desensitisation therapy

Early exposure to common food allergens before allergies develop.