SUBJECTIVE DATA William (Will) C. is a 3-year-old Caucasian boy who came to the office with a 3-month history of increased drinking and urinating. At the onset of these symptoms his parents attributed them to attempts for increased attention as a result of the birth of a new sibling and a change in child care during this period. However, the symptoms increased to the point that, according to his father, Will had become “obsessive” with respect to his need for water. He would often get up at night and get drinks from the faucet. His parents had put up gates and locked doors in attempts to keep Will from drinking so much. The polyuria also increased, and more recently enuresis occurred as well. Will’s medical history is unremarkable except for recurrent otitis media. His growth and development have been normal. Mrs. C. reports that Will’s appetite has decreased recently, and she suspects that he has lost weight. The family history is unremarkable except for late onset non-insulin-dependent diabetes mellitus in the child’s paternal grandfather.
months ago. His temperature was normal, his heart rate was 160 beats per minute, his respiratory rate was 28 per minute, and his blood pressure was 134/ 72. Urinalysis revealed a specific gravity of 1.020, and glucose was negative. During this office visit, which lasted about 1% hours, Will drank 40 ounces of water and urinated three times. Blood electrolytes and serum and urine osmolarities were obtained, and the results were all within normal limits. Despite the normal laboratory values, diabetes insipidus was suspected, and an appointment was made with the Endocrine Clinic. Fortunately, an appointment was available the next day. During that visit Will’s heart rate was 181 beats per minute and his blood pressure was 135/92. On physical examination he appeared poorly
perfused, and his cheeks and ear lobes were quite flushed with some dry patches and felt warm to touch although he was afebrile. His cheeks and ears blanched with pressure and instantly refilled. His abdomen was mildly distended but not tympan&. Otherwise the results of his physical examination were normal. Because of the hypertension and history of polyuria and polydipsia a computed tomography (CT) scan of the head was done, in the belief that the diabetes insipidus was central in origin rather than nephrogenie. This scan revealed bitemporal destructive lesions extending into both orbits consistent with Langerhans’ cell histiocytosis. Will was admitted to the hospital for further diagnostic studies, evaluation, and treatment.
CLINICAL INSIGHTS QUIZ 1. What 2. What 3. What 4. What
is the usual differential diagnosis of polyuria and polydipsia? is Langerhans’cell histiocytosis? is the treatment plan? is the prognosis?
Answers are on pages 307-308.
OBJECTIVE DATA At this office visit, Will’s weight was 29 lbs., which represented a 2 lb. weight loss since his last visit 4