1. 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: 37.1P: 126R: 30BP: 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. 14 month old male, previously healthy, with acquired hypotonia, ptosis and three week h/o poor feeding.

12. 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

14. HYPOTONIA- Differential Diagnosis