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A lesson learned?
A 20-year-old woman was referred for "thyroid disease" that was easy to eliminate based on the history, physical examination and accompanying thyroid function tests.
What got my attention were her height, 59 inches and weight, 85 lb, and a very flat affect. She had a sister 5 years younger who was also 59 inches tall but weighed 110 lb. Her father was 68 inches tall, weight unknown, mother was 64 inches tall, weight estimated to be at 120 lb.
She was doing well in her course work at the local community college, did not feel unwell and wasn't quite sure why she was seeing me as a patient. She had no major background medical history and was menstruating regularly without any medication. I was concerned about her height and weight and contacted her pediatrician, whom she had not seen for a couple of years, and requested a copy of her growth chart. It was faxed within 5 minutes and is provided below for your perusal.
My first thought was that she was growth hormone-deficient, but that was not confirmed when her baseline GH and response to arginine stimulation were normal and her epiphyses were closed. I contacted a local expert for advice because things now pointed to anorexia nervosa or a similar eating disorder, but she had regular menses. He reminded me that I had forgotten to measure insulin-like growth factor I. As he predicted, it was low but I still did not have a clear diagnosis or management plan.
On her return visit 2 weeks later, I probed further into the flat affect and ended by suggesting that she seek a psychiatric evaluation. She took this in stride and I left her with a recommendation that she visit the local community mental health program.
Fifteen minutes after she left the clinic her mother called and asked to speak to me. I thought I was in for an angry call: "How dare you think my daughter needs psychiatric care!"
What followed was quite different! Mother was in tears and kept asking how/why so many of the doctors she had seen in the past had ignored her failure to grow and that she was in trouble. Then the family history came out with details of the father's physical and emotional abuse of his daughter which resulted in divorce when my patient was 15 years old.
What I cannot come to grips with is the failure of her pediatrician to pay any attention to the carefully plotted growth chart and the failure of other colleagues to see her as a person in trouble rather than just another clinic visit. How sad!
While anorexia or other eating disorder (denied by Mandy) was staring me in the face, I was concerned about the abrupt change in her growth and development and scheduled an arginine stimulation test, IGF-I, and radiographic estimate of her bone age.
Her baseline GH was normal as was her response to arginine. IGF-I was suppressed. Her growth plates were closed.
What do you think about this case?
