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Pediatric Puzzler

Pediatric Puzzler. November 26, 2007. HPI. 14 month old male seen by PCP intially for fever and nasal congestion with purulent nasal discharge and cough. At initial visit to PCP, patient was breastfeeding but had decreased solid po intake.

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Pediatric Puzzler

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  1. Pediatric Puzzler November 26, 2007

  2. HPI • 14 month old male seen by PCP intially for fever and nasal congestion with purulent nasal discharge and cough. At initial visit to PCP, patient was breastfeeding but had decreased solid po intake. • Diagnosed with OM and sinusitis and treated with amoxicillin. After five days on amoxicillin, there was no improvement in his symptoms, so azithromycin was prescribed. • Fever and nasal symptoms resolved, but he continued to have a decreased activity level, poor oral intake, and worsening cough.

  3. ER visit • In ER, diagnosed with pharyngitis and dehydration and given IVFs and discharged. • Returned to ER three days later secondary to listlessness and persistent diminished appetite. • Mom had resorted to pumping breast milk and feeding breast milk to infant on a spoon. • Admitted for dehydration

  4. More history… • One pound weight loss over past week • No fever • No vomiting • No diarrhea • URI two weeks ago • What else would you like to know?

  5. In the hospital • No improvement on IV hydration x 3 days • Continued to feed poorly • You observe the patient attempting to feed • Choking and gagging ensues • Treated with antibiotic for positive group A Strep. throat culture

  6. In the hospital… • EGD and head CT done to rule out esophageal foreign body. • Both negative • Transferred to Children’s for further work-up

  7. You are the Admit Resident… • 14 month old with dehydration secondary to three week history of poor feeding and decreased activity level • Birth history: noncontributory • PMH: negative • Developmental History: within normal limits • Immunizations: up to date • Diet history: Breastfeeds occasionally, table foods, juice, and water

  8. You are the Admit Resident… • Social History: Lives with parents and two older brothers. One brother with psoriasis • No pets • No smokers in home • No h/o exposure to toxins • Municipal water supply

  9. Physical Exam • T: 37.1 P: 126 R: 30 BP: 117/61 • Wt: 10-25% Ht: 25% HC: 10% • Gen: tired-appearing, fussy, consoled by mom, weak cry, non-dysmorphic • HEENT: normocephalic, nares clear without drainage, TMs clear, dry mucous membranes, throat clear • CV: RRR, no murmur, good pulses • Chest: clear • Abd: benign, no masses • Ext: warm and well-perfused

  10. Physical Exam • Neuro: PERRL, difficulty keeping eyes open, gag intact, decreased tone throughout, ambulates short distance to mother without limp or ataxia • DTRs normal • Negative Babinski sign • His hypotonia strikes you and heightens your concern.

  11. Problem Definition: 14 month old male, previously healthy, with acquired hypotonia, ptosis and three week h/o poor feeding.

  12. What do you think??? Top 3 differentials Three tests you would like to order

  13. Labs • CBC • CMP • UA • Utox • TSH • Serum Amino Acids and Urine Organic Acids: Pending • CXR • ESR • VBG • Lactate, Pyruvate levels ALL NORMAL

  14. HYPOTONIA- Differential Diagnosis

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