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Toby Cartwright: The Case

Problem Based Learning guide for 1st Year medical students.
The Case

Setting: Outpatient Pediatrics Office


Toby Cartwright is a four-day-old neonate who is brought in by his mother, Mary.  Mom is concerned because he has been vomiting with every feed since birth.

In the first two days following birth, Toby was spitting up and the staff thought it might be due to intolerance to Mary’s breast milk.  He was switched to a soy formula and discharged from the hospital on the second day after birth, at the same time when mom was discharged. Mom is bringing him in because he has continued to vomit at home with progressively increasing frequency. When he vomited this morning, his vomit was bright green, like grass.

Mom has only fed Toby the soy formula since leaving the hospital.

When she offers him a bottle, he sucks strongly and drinks it all quickly, but a few minutes after finishing his bottle he vomits repeatedly. It looks to her as if all the formula she fed him comes back up, if not even more than she fed him. She has been giving him 2 ounces at a time.

She has not seen any blood in his vomit.

He has been really fussy for the last day or so and only sleeps for a few minutes before waking up and crying as if he is hungry.

She has not taken his temperature.

Birth History:

Mom has no chronic diseases. She smoked one pack of cigarettes daily both before and during pregnancy.

Mom received prenatal care throughout her pregnancy and was not told of any infections associated with the pregnancy.  She did require increased frequency of prenatal ultrasounds due to polyhydramnios.

Toby was born vaginally at 39 weeks and Mom had an epidural for anesthesia.

Toby’s birth weight was 7 lbs. 4 ounces (3300 grams).

Toby did not have any other ill symptoms in the nursery.

He was having plenty of wet diapers when she brought him home from the hospital, but he’s only had 1 or 2 wet diapers in the last day.

Mom is not sure if Toby had a bowel movement in the hospital, but Mom reports he had one bowel movement at home. It was black and sticky like tar. She didn’t notice any blood in his bowel movement.

Past Medical History:  As above.  Also, circumcised on day of life 2 prior to discharge from the hospital.

Medications: None

Allergies: None that they are aware of.

Family History: No family history of similar problems in other babies. A cousin was born with a congenital heart problem and died early in life.

Social History: Toby is the only child of Mary and Chase Cartwright.  They live in a single-family home. Father is employed at Belle of Louisville and mom works from home for an online marketing company.

Physical Exam

Vital signs:

Item Value




T 99.7 rectally
Weight 2780 grams (6lbs. 2oz.)

Gen: Toby is a fussy, pale infant

HEENT: His anterior fontanelle is sunken, and he has a vigorous suck with tacky mucus membranes. He has a normal palate and uvula. He is jaundiced and his sclera are yellow.

CHEST/CV: His lungs are clear. He is mildly tachycardic with no audible murmurs. His pulses are palpable in all four extremities. Capillary refill is prolonged at 4 seconds in his extremities.

ABDOMEN: His abdominal evaluation shows a soft, non-tender, non-distended abdomen with good bowel sounds. There are no masses and no hepatosplenomegaly.

GU: Genitourinary examination shows a circumcised male with bilateral descended testes and no hernias noted. His muscle tone is normal, with normal neonatal reflexes. No diaper rash is noted.

MUSCULOSKELETAL: His arms and legs are in the flexed position-normal for a newborn. His skin turgor appears reduced, with skin creases slow to rebound when pinched together. No deformities or signs of trauma are noted.

The pediatrician explains to Toby’s mom that she needs to take him to the hospital for more testing to figure out the cause of his problem, and calls ahead to the ER to tell them about Toby’s history.

ER Course:

In the ER, Toby is revaluated by the physician and blood tests are done as well as an x-ray followed by a upper and lower GI study, shown below.

ER Lab Results






17.1 g/dL




142 mEq/L


3.1 mEq/L


89 mEq/L


32 mEq/L


26 mg/dL


1.3 mg/dL


32 IU/L


28 IU/L


10.1 mg/dL

Direct bilirubin

0.8 mg/dL


4.1 g/dL

Anion gap






Blood Type


Direct Coombs


Reticulocyte count




Plain Abdominal Film, Supine

Abdominal Image 1

Upper GI Series: Stomach Emptying into Small Bowel

(Over 30 additional minutes, contrast did not progress further.)

Abdominal Image 2

Lower GI Series

Abdominal Image 3

The ER physician comes back into the room to explain the test findings and next steps in the plan to Toby’s mother. She asks why this happened, and what this means for Toby.

Toby is taken to the operating room emergently due to a diagnosis of midgut malrotation and volvulus. At the time of surgery, the proximal jejunum was prominently dilated with a blind end. Distally, an apple-peel deformity with extensive jejunal and ileal atresia was encountered.

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