Hot Seat #139 Denouement: 6wk M with Failure to Thrive

Posted on: October 29, 2019, by :

The Case: A 6 week-old, ex-full term (and otherwise healthy), presents from the PCP’s office for concern of lethargy in the setting of an abnormal thyroid function studies on newborn screen.

Here’s how you answered the questions:

Discussion

Thankfully, a pre-arrival not reflecting a patient’s current clinical status is a rare occurrence. Joking aside, and as many said, this reflects the importance of reaching out to the referring provider for more clarification. While Dr. Agrawal accurately calculated what would appear to be an “appropriate” weight gain for this infant, 1.) the numbers were not reflective of the clinical case and 2.) a conversation with the PCP revealed that the infant was in fact falling off the growth curve, adding concern that something more serious was going on.

Before jumping into the medical issues of the case, many pointed out that it is also important to note that a parent may be sleepy for many reasons (sleep deprivation, chronic medical comorbidities) and it is very important to speak with the parent directly before jumping to any conclusions as to the why.

In terms of the management of the case, most thought it would be  appropriate to attempt to feed the baby after discovering the low blood sugar (baby is vigorous and by report feeds well). A few mentioned attempting to give oral glucose gel, but noted that this may not be available in all EDs. Following the correction of the sugar with D10W, everyone agreed that it would be important to observe the child for further episodes of hypoglycemia and disposition should be based on a discussion with Endocrinology and the monitoring needs of the child.

Denouement

The patient was admitted to the endocrine service. Further workup revealed undetectable cortisol level, and an MRI revealed an empty sella, leading to a final diagnosis of panhypopituitarism.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Brian Lee
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