Professional Documents
Culture Documents
Case Presentation
APRIL 1, 2019
Case: Initial Presentation
5 month old previously healthy term male directly admitted for failure to thrive work-up after failing outpatient
management.
HPI:
- PCP concerned patient has only gained 4 ounces in last month
- Mom reports long-standing issues with feeding
◦ Good latch but “falls off” after 1-2 minutes
◦ Refuses bottles
◦ Previously had success with SNS but recently has refused to take milk via SNS
- Does not get sweaty or appear tired with feeds; no cyanosis or diaphoresis.
PMH:
- Term, uncomplicated pregnancy and nursery course
- ED visit 3 months prior to admission for BRUE
◦ Baby crying and appeared pale with acrocyanosis
Case: Initial Presentation
Admission Examination:
VS appropriate for age
General: Alert, no acute distress, playful and interactive.
HENT: Unremarkable
Lungs: Clear to auscultation. no increased work of breathing
Heart: Normal rate, regular rhythm, 2/6 systolic murmur at LSB [c/w innocent murmur], 2+ peripheral
pulses. Normal cap refill and no cyanosis.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds. No HSM.
Musculoskeletal: no edema
Skin: Skin is warm, dry and well perfused, no rashes or lesions
Neurologic: Alert, grossly normal.
Growth Chart:
◦ HC 6th %ile (Birth 21st %ile)
◦ Length <3rd %ile (Birth 23rd %ile)
◦ Weight <3rd %ile (Birther 30th %ile)
Common Conditions
◦ Abnormal Feeding
◦ Baby—poor coordination, hypotonia, latch issues,
congenital abnormalities (cleft)
◦ Parent—latch issues, low supply, incorrect formula mixing
Case: ◦ Infection
◦ GI Disorders
Differential ◦ GERD—Minority with related feeding refusal, inadequate
caloric intake
Diagnosis ◦ Pyloric Stenosis
◦ Milk Protein Allergy (about 2% of children <4 years)
◦ Child Abuse/Neglect
◦ Social Factors
◦ Food insecurity
◦ Inadequate housing/access to care
Case: Differential Diagnosis
Life-threatening or Serious Conditions
◦ Congenital Heart Disease
◦ Intermittent Intestinal malrotation
◦ Inborn Errors of Metabolism
◦ Intestinal Malabsorption (congenital chronic diarrhea)
◦ Kidney Disease/Failure
◦ Cystic Fibrosis
◦ Malignancy
◦ Neuroblastoma
◦ Nephroblastoma
◦ Acute leukemia
Case: Work-up and Diagnosis
On HD1, patient re-examined and the following anomalies found:
• Harsh 4/6 midsystolic murmur audible throughout precordium with palpable thrill
• Hepatomegaly (5cm below CM)
Cardiac Work-up:
Not all serious CHD will present in the first days of life