Hot Seat Case Denouement: 2 week-old tachypnea

The Case
by Joelle Simpson
This is a 2 week old full-term infant with 3 days congestion and cough x 1 day that you receive on signout. The provider signing out says that she is concerned because the baby has had tachypnea to 80s, has a mottled appearance to the skin. The patient appears comfortable otherwise and  otherwise has no significant exam findings. A CXR was unremarkable. The infant has been observed in the ER for 8 hours and has fed well despite tachypnea.

ROS: Afebrile, non-fussy, normal po intake, normal number of wet diapers. Emesis x 1 after feeding 1 day ago. Has 1 prior ED visit at 6 days of life for fussiness attributed to gas. No known sick contacts.

Birth history: C-section due to placenta previa. No problems during pregnancy, delivery, or after birth.

Fam Hx: Father had recent heart surgery to repair damaged heart valve. Mom reports that her  first child died at 2 months of age. Mom believes the child died because of mismatch with maternal blood and reports the child stopped eating, had no bowel movements for 1 week, had no urine output and swollen abdomen. Two other siblings are well.

Exam:
Vitals T 37.3; HR 154; RR 80; BP 97/65 O2 sat 100%
Alert, tachypnea, and mottled skin
Lungs CTAB with substernal retractions  
RRR, no murmurs, 2+ femoral pulses
Rest of exam is unremarkable

Teaching Attending Response 
by Pavan Zaveri
Well, there has been quite the response to this case. The neonate always brings up quite an emotion. The differential thus far offered includes:
Infection: SBI, RSV/bronchiolitis, HSV, Sepsis
Other: anemia, metabolic disease, congenital heart disease, NAT, periodic breathing
"ALTE" though it's a symptom, not a diagnosis
Workup could be from something to everything.

On a different note, once this long (8 hrs) an observation period has passed (2% of this kid's life), it is always imperative to go back and look for lurking clues the parents and the infant have to offer. Nursing input can also be invaluable as they may have been complicit with the 8 hour stay as they felt something was not right but unable to identify it nor willing to subject the infant to tests. Often, asking the caregivers (nurse, parents, grandparents, etc.) what they are most concerned about can yield surprising results and not only a comforting few words from you but also a direction for the workup.

Looking forward to the denouement soon.

Your Responses:

Would you do any additional testing beyond a chest x-ray in the ED?

If you do choose to test, what additional tests would you do?

Would you choose to admit this baby?

Case Denouement 
by Joelle Simpson
The overall work up in the Emergency Department included a CXR, CBC, EKG and an echocardiogram. Cardiology had been consulted and was performing an echo at the time of provider signout. The echo revealed that the patient had a small secundum atrial septal defect versus a patent foramen ovale. Unfortunately, my examination of the child's respiratory pattern was limited by the fact that the echo took 90 minutes to complete (aka we are a teaching hospital). The EKG was unremarkable. Given the prolonged Emergency Department stay and the significant exam findings and suggestions for admission noted by the prior provider, the patient was admitted to the Hospitalist service. 

Upon decision to admit, labs were requested revealing the following: CBC with a WBC of 18.6 with Hgb/Hct of 12 and 33 respectively. The differential was unremarkable. All parties involved decided that empiric antibiotics and further sepsis work up was not necessary in the Emergency Department given the overall well appearance of the infant otherwise. Electrolytes were drawn with a Na of 130, K of 4.9, Cl of 98 and CO2 of 25; CRP was 0.05.  The patient was admitted to the Hospitalist service and was eventually diagnosed with periodic breathing of a newborn. During floor observation the respiratory rate ranged from 28 - 65 and the patient continued to feed well. Per the PMD, the patient continues to do well and is thriving.