Presentation on theme: "Case of a 16 Year Old Male That “Can’t See, Can’t Hear”"— Presentation transcript:
1 Case of a 16 Year Old Male That “Can’t See, Can’t Hear” Teresa M. Carlin, MDAssistant ProfessorDepartment of Emergency Medicine and PediatricsJohns Hopkins UniversityBaltimore, MD
2 Case Presentation 17 yo male presents to the ED CC: “I can’t see” triage assessment:normal vital signsgrossly normal visionoutcome:left waiting room prior to physician evaluation
3 Case continued Represented to ED 24 hours later CC: “can’t see, can’t hear”triage assessment:normal vital signsgrossly normal visiongrossly normal hearing
4 History Source: per patient CC: can’t see and can’t hear ROS: could not elaborate furtherROS:denied recent illnessesdenied nausea, vomiting, diarrheadenied fevers, chills, URIdenied rashesoccasional headache
5 History PMH/PSH: unremarkable Medications: none Allergies: none SH: has one childlives with momoccasional ETOH and marijuanadenied other illicit drugs
6 ExamBright and alertwalked into the treatment area without difficultyVS: 37.5*C, HR=72, BP=130/70, and RR=14
7 Exam HEENT: NECK: EOMI and without nystagmus muddy sclerae pupils mid-sized and reactiveTM’s normal blNECK:suppleno adenopathyno bruits
8 Exam CV: RESP: regular rate and rhythm no murmurs, rubs, or gallops nondisplaced PMIRESP:CTAunlabored
9 Exam Abdomen: Skin: Extremities: soft, nontender, nondistended negative masses or hepatosplenomegalynormal bowel soundsSkin:negative purpura, petechiae, rashes, or track marksseveral tatoos on arms and backExtremities:well perfused, no edema
10 Exam Neuro: alert normal gait equal strength throughout, normal tone followed simple directions:could see and pick up a pen and identify itasked in normal tone of voice
11 Exam Neuro: directions frequently repeated ‘huh’ and ‘don’t know’ typical teenage behavior?seldom used full sentencesyes, no responsesunable or unwilling to cooperate with further examannoyed and frustrated“going home”
12 After Exam Patient jumped off gurney found restroom without assistance returned to treatment room without difficultylater found wandering in the hallway“Huh?”, “Huh?”, “Waiting for my mom”redirected to roomfell asleep
13 Cousin’s History Normal state of health until 2 d PTA 2 d PTA : arrested for possession of marijuanahead banging while in cellchoked???released to custody of mother early morningnot acting like selfjail experience
14 Cousin’s History 1 d PTA: (first ED visit) awoke c/o “headache” and “can’t see”sleeping ALL DAY LONGsquinting and intermittently covering one eyebumping into things at homedid not make sense when he talkednot acting like his normal self
15 Summary 17 yo male not acting right not cooperative with exam headache“can’t see, can’t hear”not cooperative with examteenager or pathology2nd ED visit for same complaintchange from baseline mental statussleeping a lotnot making sense when he talks
16 Questions? What is the differential diagnosis? What initial laboratory tests should be drawn?What ancillary studies should be ordered?
17 Altered Mental Status Common Causes Cerebrovasculartraumaspace occupying lesionseizure relatedstrokehemorrhagePsychiatricpsychosissevere depressionHypoxia/hypercarbiaInfectionmeningitisencephalitissepsisToxictoxicity/withdrawalenvironmentalMetaboliclytes, endocrineliver, kidney
19 Results All blood work is NORMAL EKG and CXR are NORMAL Tox screen is positive for THC
20 Evaluation continuesPatient instructed to get into wheelchair for head CTPatient responded (fluently):“Chairboot flies to the baseball”Cousin responds:“that’s what he has been doing”“he ain’t making no sense”Do you expect the CT to be abnormal?
21 Head CT Results Head CT/MRI are ABNORMAL bilateral watershed strokes between MCA and PCA distributionsleft frontotemporal parietal lesionwatershed between MCA and ACA
22 ED Management of Pediatric Stroke Extrapolated from adult literatureIV, O2, and monitorprevention of stroke evolution:ASA therapyanticoagulants - likely benefit if:arterial dissection, prothrombotic disorder,dural sinus thrombosis, embolic source identified thrombosis
23 ED Management of Pediatric Stroke too late for thrombolyticsCT evidence of strokesymptoms for at least 48 hoursusefulness in pediatric stroke????
24 Hospital Evaluation ASA therapy MRI, MRA, MRV echocardiogram and bubble studyvalves, thrombus, PFOtranscranial and carotid duplex
25 Hospital Evaluation hypercoaguable studies HIV testing Lumbar puncture PT/PTT, INR, Factor V leiden, homocysteineprotein C and S, antithrombinIIIanticardiolipen antibodyHIV testingLumbar puncture
26 During Hospital Course Wernicke type aphasiavisual agnosiafluent speech, poor content + circumlocutionsimpaired naming of visual stimuli but ok with tactile stimulisemantic paraphrasias and neologistic jargonnormal motor exam
27 Outcome Etiology of stroke never identified Theory: Progress: acute occlusion of bilateral carotids by manual pressure? Strangled in jailProgress:continues with visual perceptual problemsaphasia that interferes with his ADL’simpaired auditory comprehension
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