Welcome to this month’s What’s Your Diagnosis Challenge!
Case Presentation: a 6-month-old boy who presents with poor weight gain
Your first patient is a previously healthy, vaccinated 6-month-old boy who presents with poor weight gain. The child has been seen by his primary care provider multiple times within the last several weeks, and the mother is very concerned because he has not shown any improvement.
The child was born at term via spontaneous vaginal delivery, did not spend any time in the NICU, and has been well. Despite this, in the past 2 months, the patient has gone from the fiftieth percentile on his growth curve to less than the thirtieth percentile.
The patient has not had any vomiting or diarrhea and has been urinating and moving his bowels normally.
On physical examination, he is smaller than expected, but otherwise his vital signs are unremarkable, as is the remainder of his physical examination.
You inform the family you are going to review his chart, and as you leave the room, you wonder what is going on with this patient.
Could it be a metabolic or cardiac abnormality? Is it a problem with the gastrointestinal or respiratory system? What if this is a manifestation of neglect? What tests should you order for the patient? Should you be starting him on IV fluids? Should this patient be admitted to the hospital or discharged home? Do you need to call social work?
The 6-month-old patient?s primary care provider was within your hospital?s network, so you were able to review her notes and confirm that the patient had indeed been losing weight over the past 2 months. The PCP had tried to identify the cause of the patient?s weight loss but was not successful. The PCP had tried increasing the feeding volume and frequency and placed the patient on a high-calorie formula, but he still lost weight. Your history and physical examination did not identify any other obvious cause for nonorganic or organic FTT, and there was no evidence of abuse or neglect. At this point, you decided to order basic screening laboratory studies for organic causes of the patient?s weight loss. The patient?s CBC did not show evidence of anemia or infection. The BMP did not show signs of dehydration or electrolyte abnormalities. The UA did not show signs of infection or glycosuria. However, the TSH was depressed, and follow-up testing for free T4 was elevated. The patient had no evidence of thyroid storm and otherwise remained hemodynamically stable. You consulted endocrinology; the endocrinologist recommended supportive care and admission to the hospital, and said she would evaluate the patient in the morning. You spoke to the admitting team, and the patient was placed in the hospital for further workup and management.
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