Hot Seat #161: 3mo with poor feedingPosted on: November 30, 2020, by : Mary Beth Howard
Nicole Barbera, MD Inova Children’s Hospital
CC: Poor feeding, sleepy
HPI: 3 month old previously healthy male who presents to the ER with 2 days fussiness followed by increased sleepiness and poor feeding starting the night prior. No fever. He had 2 episodes of non-bloody nonbilious emesis. No changes in voiding or stooling. No cough or congestion. No known sick contacts. Born at 40 weeks gestation via NSVD, GBS and all prenatal labs negative, birth weight 3.2kg and gaining wait well since. Immunizations UTD.
Exam: HR 140, BP 86/54, RR 40, SaO2 100% on room air, Temp 99.2, Wt 7.5kg
Well appearing in no acute distress, sleeping throughout exam except when lifted and held in a seated position. Anterior fontanelle is open/soft/flat, moist mucus membranes, no oral lesions. Lungs CTAB, heart RRR, strong femoral pulses, no murmurs, brisk capillary refill. Abdomen is soft, nondistended, nontender, no hepatosplenomegaly or masses. Uncircumcised, testes descended bilaterally. Skin warm and dry, no rashes.
Point of care glucose 113.
Abdominal x-ray and US are negative for intussusception. CBC unremarkable. CMP notable for AST 228, ALT 174 otherwise within normal limits with total bilirubin of 1.2. Vitals stable, patient remains sleepy but easily arousable on exam.
Further labs obtained with GGT 776, CK 97, LDH 490, alk phos 273, coags within normal limits.
RUQ US showed 7mm gallstone within the gallbladder which has multiple septations and wall thickening. The common bile duct is 6mm and dilated to the pancreatic head. Liver normal.
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