Diagnosis & Medical Plan

Diagnoses & Comments

Principal Final Diagnosis:
1. Failure to thrive

Additional Diagnoses:
2. Septo-Optic Dysplasia
3. Absence of Corpus callosum
4. Optic Nerve Dysplasia

Hospital Course:
Anthony Rodriguez is a 7 month old term infant, admitted on 01/04/12 with 6 months of poor feeding, excessive vomiting, failure to thrive, microcephaly, and global developmental delay; found to have septo-optic dysplasia with absent corpus callosum on MRI and impaired gastric motility.

FEN/GI
Anthony was admitted on 01/04/12 and found to be <3rd percentile for weight and head circumference. At the time of admission, he was being maintained entirely on donated breast milk. On hospital day #3 (HD#3) due to concerns for weak suck and general hypotonia, modified barium swallow study was performed along with upper GI study, which showed no aspiration events or malrotaion of the gut, but did demonstrate -50% air swallow and greatly delayed gastric emptying. NG Tube was discussed with the parents, who elected to try medical therapies first. Erythromycin was started at 10 mg/kg every 8 hours to promote gastric motility.

Nutrition consult was also obtained, and fortified feeds with breast milk and Similac Sensitive formula for 24 cal/ounce was recommended. Feeding schedule for 3 oz every 2 hours was recommended and implanted on HD#3. Parents implemented this schedule and demonstrated understanding of his nutritional needs. Yecenia was seen by lactation consultant to assist in effort to transition from donated breast milk to her breast milk.

Anthony did not demonstrate the excessive vomiting on the fortified breast milk that the parents had previously reported with formula. He demonstrated appropriate weight gain during the hospitalization from 5.74 kg on admit to 6.1kg on discharge. He went home with the above feeding plan, and instructions for close follow up with PCP. At the time of discharge, Zinc and 25 OH Vitamin D levels were pending.

Neurodevelopment
Anthony was admitted with concern for general hypotonia, microcephaly, and failure to meet developmental milestones. He demonstrated signs of abnormal brain development on exam, such as persistent cortical thumbing. MRI was obtained under sedation on HD#2 and showed septo-optic Dysplasia with absence of the corpus callosum and dysplasia of bilateral optic nerves and the optic chiasm. Variability in expression of this disorder was discussed with the family, as was the need for extra developmental support to assist in meeting developmental milestones as normally as possible. Plan was made for Anthony to follow up in CDRC Outreach clinic in Medford.

Ophthalmology
Anthony’s parents expressed ongoing concerns with Anthony’s ability to track faces or objects visually, and on exam he was not noted to track faces or objects with his eyes. After the MRI showed septo-optic dysplasia, ophthalmology was consulted and performed bedside eye exam which confirmed hypoplasia of bilateral optic nerves. It was their opinion that he did have light response and occasionally did appear to focus on objects. As it is difficult to truly determine visual acuity in an infant of his age, follow up in Casey eye Center was recommended for 3 months from discharge. Parents were instructed on maintaining good visual stimulation with toys and faces in the interim.

Endocrine
After the diagnosis of septo-optic dysplasia was made, endocrine consult was placed as many children with this diagnosis have associated hormonal deficiencies. TSH, cortical and Cortrostym test, Free T4, and serum and urine osmolality were checked and were normal. Serum electrolytes were also checked and were normal. At the time of discharge, growth hormone studies were pending.

Infectious Diseases
Anthony has not received any of the usual childhood vaccinations to date due to parents preference. This was not discussed in great length during hospitalization. He will require follow up in regards to the need for immunization in future PCP visits.

FOLLOW UP PLAN

Follow up with PCP Dr. Cherry in Klamath Falls in 2-3 Days.
Follow up with DCRC Feeding Clinic in Medford in 1 month: February 16, 2012
Follow up with Casey eye in 3 months: April 20, 2012