Dr Miriam Grotowski discusses the importance of knowing when it’s time for questions and when it’s time to act.

A MOTHER brought her 10-year-old daughter to see a colleague in our regional practice reporting tiredness, lethargy and snoring.

History revealed no temperatures or sweats, arthralgia or arthritis. There was no history of upper respiratory tract infections, no gastrointestinal symptoms other than constipation and a normal appetite.

The symptoms had been present for at least six months. She was fully immunised, and there was no significant neonatal or past surgical or medical history. No one else in the family had been unwell or travelled outside Australia.
Specifically there were no obvious family issues or observable anxiety or depression.

Tests for Ross River and Barmah Forest, Epstein-Barr virus and a full blood count were normal and the family was reassured, however they returned some two months later with concerns about the lethargy.

A referral to an ENT surgeon was made who felt the tonsils/adenoids were not significantly enlarged enough or the likely cause of her symptoms and thought there was little value in tonsillectomy.

With still no improvement in symptoms, a referral was made to a paediatrician who completed basic bloods (all normal) and after persuasion from the family a referral was made to another ENT who performed the surgery.

I first saw her 10 days post surgery with a significant post-operative bleed. This rendered her hypotensive requiring urgent air transfer and transfusion of two units of blood.

Two weeks later she presented with her mother seeking a further medical certificate excusing the girl from sports. I noted her then to be pale, with reduced body hair and on checking the growth centiles noticed she had not gained any height in 18 months. Her weight had stayed more or less the same on the 90th percentile.

The differential at the time was that of a transfusion reaction and subsequent anaemia. Tests including a blood count and electrolytes, a reticulocyte count and a TSH were ordered.

A GP registrar on call for the practice received a call from the lab noting a high TSH result which they had calibrated as >1700.

The registrar noted this but failed to act on it over the weekend and the result appeared in hard copy in my in-tray on Monday.

A quick response followed involving consultation with a paediatrician and upon repeating the test the same result. The diagnosis of hypothyroidism was made.

Oroxine was commenced and the patient has recovered and is no longer tired.

The salient lessons:
1) It’s worth checking percentile charts in older children, and the more values you have the better the tool (the advantage of regular attendance at a general practice).
2) Just because patients have seen multiple doctors, always use your eyes and ears and keep thinking of underlying diagnoses.
3) If a report sounds unusual, do something. If a lab rings on a weekend, it may be serious and they can discuss results or likely implications even after hours.