ID:
5mo female with a history of multiple food allergies, GERD and FTT admitted from clinic for persistent failure to gain weight.
HPI:
The patient’s mother states that the current diet is 3oz of Neocate 20cal/oz q3h, and that the baby sleeps through the night. The child has a history of reflux, but no emesis in the past few weeks since starting Reglan. There was a history of bloody diarrhea, however none since age 2mo after a change of formula. Mother reports known allergies to milk, soy, protein, and egg. No recent fevers/chills, emesis, diarrhea, fussiness.
The patient was born at 27wks via emergency Cesarean for non-reassuring fetal heart tracings, was intubated in the DR and remained in the NICU for one week.
PE:
- VS: 98/65mmHg, 114bpm, 98.1°, 33/min, 100% RA
- Gen: Small for age, smiling and interactive
- HEENT: PERRL, MMM, no lesions
- CV: RRR, no M/R/G, Lungs: CTAB
- Abdomen: +BS, soft, NT/ND, no masses, no hepatosplenomegaly
- Ext: Normal capillary refill
Assessment & Plan:
5mo female, ex-27wks with a history of multiple food allergies, GERD, FTT. Persistent failure to gain weight, admitted for evaluation of feeding habits and observed weight gain. The patient was determined to not be receiving adequate intake and was advanced to a high-calorie formula and parental education was provided. After two days of observed (and appropriate) weight gain, the patient was discharged with follow-up at multiple specialty clinics including GI, FTT, and A&I.
Differential Diagnosis for Failure to Thrive:
