Session 2 Assignment: If the patient we discussed this session (child with fever but no sign of infection) had been a 6-week old, what would we do differently?

If our patient was a 6-week old infant, I would refer the patient to the ED for a full septic work-up since there is a rectal temperature of >101.48 F rectally and no obvious sign of infection due to greater risk of invasive bacterial infection (IBI).

1. 1. MCC – viral, but differentials basically the same
      1. Rhinovirus > RSV > influenza > parainfluenza
      2. Still significant risk of UTI in this age group
      3. Need to think about vertical transmission from mother during delivery (more so in first month though) as well as from family members postnatally
   2. Take more seriously than older infants and children because immune system is less developed — less T cell-mediated immunity
   3. Group B strep and e coli for meningitis 

Session 3 Assignment: A new 16-year-old patient is seen by a pediatrician for the first time before beginning her school year. Her family just moved into town. Her PMHx is significant for recent hospitalization for SCFE 6 months ago and she underwent internal pinning of the left hip. Her growth curve shows declining growth velocity from the 50^th percentile to the 15^th percentile. Her weight is in the 85^th percentile. Her mother noted that she is tired and sleeps most of the day, but she attributed that to her being a teenager on summer vacation. Her PE is within normal limits and she denies trouble falling or staying asleep. What is the differential diagnosis, next step in management, and potential treatments?

Differential diagnoses:

• Endocrine disorder
  • Hypothyroidism – commonly associated with SCFE
  • Type 2 diabetes
  • Cushing Syndrome
  • Growth hormone deficiency
• Depression
• Obstructive sleep apnea
• PCOS
• Chronic fatigue syndrome
• Iron deficiency anemia
• EBV infection

Next steps:

• Thorough history
  • How long has she been feeling tired?
  • Sleeping habits
    • What time does she usually go to bed and wake up?
    • Does she snore/sound like she stops breathing?
    • Does she wake up feeling rested?
    • Does she have to take naps during the day?
      • If yes, does she feel better after?
    • Any parasomnias?
  • Any recent sore throat?
  • Any fever, dizziness, or lightheadedness?
  • Recent weight gain
    • All at once or gradual?
  • Changes in hair/skin/nails
  • Is anyone else feeling tired or sick at home?
  • Past medical history
  • Daily medications
  • Surgical history other than SCFE
  • Family History
  • Social history
    • Changes in school performance?
    • Assess diet and exercise habits
  • Gyn history
    • Age of menarche
    • Regularity/ time between cycles
    • Heaviness of menstruation
    • LMP
  • Depression screen
    • Modified PHQ-9 for adolescents (1, page 22)
  • Physical exam, thorough, but specifically looking at:
    • Vitals
    • General appearance
    • HEENT
      • Hair distribution
        • Eyebrow hair distribution
        • Hirsutism
      • Conjunctiva color
      • Oral mucosa color
      • Periorbital swelling
      • Specific facies
      • Tonsil size
    • Neck
      • Thyromegaly
      • Acanthosis nigricans
      • Buffalo hump posteriorly
    • Skin
      • Dryness/thinning
      • Skin turgor
      • Color
    • Lungs
    • Heart
      • Rate/rhythm, murmurs
    • Abdomen
      • Organomegaly
      • Purple striae
      • Central obesity
    • Musculoskeletal
      • Thin limbs/deltoid atrophy
    • Neuro
  • Labs
    • CBC
    • CMP
    • TSH with reflex to free T4
    • HgbA1c
    • Lipid panel
    • If all of those are normal/depending on history and PE
      • Morning serum cortisol
      • Sleep study
      • Bone age study, IGF-1, and IGFBP-3
      • Gyn referral for transabdominal ultrasound, androgen levels
      • Cortisol suppression test/MRI of pituitary gland

Given the information given in the case and a thorough search of UpToDate, hypothyroidism seems like the most likely cause for her symptomatology.

Treatments:

• In general, diet and exercise plan to get her down to a normal BMI
• Hypothyroidism
  • Refer to a pediatric endocrinologist
  • Levothyroxine 2-4mg
    • Recheck TSH and free T4 in 6-8 weeks and adjust dose if necessary
    • Monitor every 6-12 months once stable
    • Continue therapy until at least the end of puberty and development, then reassess the need for permanent levothyroxine treatment
  • T2DM
    • Diet and exercise
      • Re-evaluate HgbA1c in 3 months
      • Metformin if not improved
        • May also help with PCOS symptoms
      • Cushing Disease
        • Transsphenoidal resection of pituitary adenoma
      • Growth hormone deficiency
        • Somatotropin injections
      • Depression
        • Refer to pediatric psychiatrist
        • Combination CBT and SSRI (Prozac or Zoloft?)
        • Exercise plan
      • OSA
        • Resolve whatever the etiology is
          • Adenotonsillectomy
          • CPAP
        • PCOS
          • Oral birth control
          • Metformin
        • Chronic fatigue syndrome
          • Structured exercise plan
          • Relaxation techniques at bedtime
        • Iron deficiency anemia
          • Supplemental dietary iron
        • EBV infection
          • Supportive care

1. https://www.med.unc.edu/ihqi/files/2019/03/Adolescent-Depression-Screening-and-Initial-Treatment-Toolkit.pdf
2. https://www.uptodate.com/contents/evaluation-of-suspected-obstructive-sleep-apnea-in-children?search=obstructive%20sleep%20apnea%20adolescent&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
3. https://www.uptodate.com/contents/infectious-mononucleosis?search=ebv%20in%20adolescent&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
4. https://www.uptodate.com/contents/overview-of-the-treatment-of-cushings-syndrome?search=cushing%20syndrome%20children&topicRef=125&source=see_link
6. https://www.uptodate.com/contents/acquired-hypothyroidism-in-childhood-and-adolescence?search=hypothyroidism%20adolescent&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1