Hot Seat #5, The Denouement: Headache & Decreased Appetite

This case was written by Priya and is about a 15 year-old with a headache and reports of losing taste for certain foods associated with weight loss. His exam was unremarkable. The headache improved with fluids and ibuprofen. 

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Here's how you responded:

1. In this patient with resolving headache but losing taste for food and weight loss, do you want any labs?

2. If yes, what labs do you want? (Select all that you would order initially) 

3. Do you want any head imaging?

Hot Seat Response 

by Julia LaJoie

Hi Sonny sorry it has taken me a while to get to this but I had this little thing called a Triathlon to do yesterday ;). Now this is a case that is easy to blow off because 1. the headache started later in the day, not the kind that wakes you up in the early morning hours which is concerning for increased ICP. 2. It is getting better and there are no focal neurological deficits. But there are a few things I like to test in all pre-syncopal or syncopal patients. What were the Orthostatic VS? Also, what is the urine dip? In this patient I would expect to see ketones in the urine and if they are not there I would go on to test glucose and electrolytes. I know you said the neurological exam was negative but when the patient and family mention a loss of weight and a change in taste sensation I would worry about a pituitary adenoma. I would go back a check peripheral vision very carefully on my exam. The heart rate is still fast after the bolus so a TSH to screen for hyperthyroidism, especially in light of the weight loss. You give the option of checking electrolytes but unless you have blood drawn before the bolus this might be misleading because you will miss hyponatremia. If I have that pre-bolus blood I'd probably send a BMP and a TSH. I wouldn't make the family wait for the TSH but I'd call the PMD and arrange for follow-up with the PMD and Neurology if the weight loss and taste changes persist or the TSH returns high as he probably needs an MRI. Finally, I'd admonish him to stay well hydrated and eat small frequent meals. Oh yes, while they are dipping the urine for ketones they should probably do a urine drug screen as well.

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The Denouement

by Priya Gopwani

As it turns out, the etiology of this patient’s symptoms was elicited through further history taking, and no labs or head imaging were obtained.  

In talking to the patient further, he started off by saying “I don’t know, I just don’t like the way certain foods taste anymore” to finally verbalizing that the reason he did not like the taste of certain foods any longer is that they reminded him of his aunt, with whom he used to live. He lived with this aunt for years, and only moved in with his parents when she passed away a few years ago. He spent years watching her health worsen from cancer until the day she passed away, and they were very close. 

The mother notes that his “picky eating” has progressed over the last 1-2 years, where most foods remind him of his aunt and he is unwilling to eat them. She further explains that although he is high-achieving in school, he does not want to spend any time with friends or family, and prefers to lay in his bed after school. He does not enjoy participating in activities with friends or family. He reports difficulty concentrating and difficulty sleeping. He seems to wake up very early in the morning and cannot fall back asleep. He denied suicidal or homicidal ideation. 

I obtained resources from psych regarding grief counseling as well as depression and provided these to the family. The mother later told me that she had suspected that her child was depressed, but was unable to get him to talk about it before this ED visit.