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December 28, 2011

David Levy

MORNING REPORT

*The editor has taken some creative liberties with the story for educational and dramatic purposes

*

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HPI: 2-week old male with jerking movements of arms and legs. Started withinfirst few days of life. Occur daily but unsure how many times each day and notworse at any part of the day. Seem to be symmetric for UE and LE, and eachlasts a few seconds. Mom went to PCP at 5 days of life and was told they were

normal (possibly benign myoclonic jerks). No eye deviation. Active and awakeafter episode. Feels like overall tone normal (compared to siblings). No knowntrauma.

PMH: None

Birth Hx: NSVD at 38 4/7 weeks to 28 yo G3P2002. Apgars 7 (2 off for color, 1off for tone), 9 (1 off for color). Birth wt 3.06kg. No maternal meds or vitaminsduring pregnancy. Reportedly all was normal at visits during pregnancy.

Imm: Received HepB in nursery.

ROS: Stools transitioned. No fevers, no low temperatures. No lethargy. Noexcessive irritability. No cough, no congestion, no rashes. Otherwise negative.

Diet: Similac since 3 days of life (prepared by parents only). Had tried breast-

feeding for first 3 days but mom did not feel she was making enough milk.

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Meds: None

Allergies: None

Family Hx: MGM with thyroid problems (think low).

Social Hx: Parents from Bosnia, and moved to US about 8 years ago. Livesat home with parents and 2 older siblings (both born in US). Mother isprimary caregiver.

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VS:Wt 2.98kg (5%), Ht 52.5cm (48%), OFC 35cm (54%)T 36.8, HR 178, RR 42, BP 88/52, SO2 98% on RA

PE:GEN: Awake, alert, crying.HEENT: NC/AT, AFSOF. Conjunctiva clear, sclera anicteric. Nares patent, nonasal drainage. MMM

CV: Tachycardic, normal S1, S2. No murmurs. Capillary refill

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DIFFERENTIAL?

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Labs:iSTAT 7.4/44/42/27/2; Na 135, K 5, CO2 28, Gluc 95, Hgb 13.3, Hct 39, iCal0.74

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Labs:CBC: WBC 9.7 (Band 1, N 24, L51, M 19, E 4), Hct 39.4, Plt 581

CMP Na 132, K 5, Cl 94, CO2 26, BUN 8, Creat 0.58, Gluc 65, Ca 5.9, prot 6,alb 3.4, tbili 7.4, alk phos 164, ALT 25, AST 42, Phos 10.9 (high), Mg 1.3 (low)ical 0.74Vit D 25-OH, 21 (low)Vit D 1,25-OH 89 (high)PTH 42 (low-normal)

UA: pH 7, Hgb Trace, WBC 10, Epi 25, Bact negative

Micro:

Blood Cx: NGTDUrine Cx: 1000 CFU Staph epiCSF Cx: NGTD (1mL bloody obtained, so no counts)

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Head CT: There are multifocal areas of diffuse heterogeneous attenuation in thecortex and subcortical white matter, most prominent in the anterior frontal lobe.

This finding could be an early manifestation of meningoencephalitis. MRI wouldbe most helpful to identify any areas of abnormal enhancement or other signsof meningitis.

Brain MRI: Midline structural anatomy shows normal formation of the corpuscallosum, brainstem, and cerebellum. Pituitary and pineal regions incraniocervical junction appear normal. Normal diffusion-weighted imaging,normal T1 and T2, normal MR imaging after contrast.

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NEONATAL HYPOCALCEMIA

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Calcium Phosphorus

PTH

Vitamin D

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PSEUDOHYPOPARATHYROID

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REFERENCES

Lenstrup E. The phosphorus content of Human Milk and Cows Milk. Brit

Journ Biochem. 1988: 193-202

Zhou P, Markowitz M, et al. Hypocalcemia in Infants and Children. Pediatrics.

2009: 189-194.

Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference

intakes for calcium and vitamin D from the Institute of Medicine: what clinicians

need to know. J Clin Endocrin Metab. 2011: 96:53.

Schafer AL, Shoback, DM. Hypocalcemia. Primer of Metabolic Bone

Diseases, Eighth Edition (in press).

http://www.endotext.org/parathyroid/parathyroid7/parathyroid7.htm

http://trialx.com/curetalk/wp-

content/blogs.dir/7/files/2011/05/diseases/Pseudohypoparathyroidism-2.jpg

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