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Case of a 16 Year Old Male That “Can’t See, Can’t Hear”

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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, MD Assistant Professor Department of Emergency Medicine and Pediatrics Johns Hopkins University Baltimore, MD

2 Case Presentation 17 yo male presents to the ED CC: “I can’t see”
triage assessment: normal vital signs grossly normal vision outcome: 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 signs grossly normal vision grossly normal hearing

4 History Source: per patient CC: can’t see and can’t hear ROS:
could not elaborate further ROS: denied recent illnesses denied nausea, vomiting, diarrhea denied fevers, chills, URI denied rashes occasional headache

5 History PMH/PSH: unremarkable Medications: none Allergies: none SH:
has one child lives with mom occasional ETOH and marijuana denied other illicit drugs

6 Exam Bright and alert walked into the treatment area without difficulty VS: 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 reactive TM’s normal bl NECK: supple no adenopathy no bruits

8 Exam CV: RESP: regular rate and rhythm no murmurs, rubs, or gallops
nondisplaced PMI RESP: CTA unlabored

9 Exam Abdomen: Skin: Extremities: soft, nontender, nondistended
negative masses or hepatosplenomegaly normal bowel sounds Skin: negative purpura, petechiae, rashes, or track marks several tatoos on arms and back Extremities: 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 it asked in normal tone of voice

11 Exam Neuro: directions frequently repeated ‘huh’ and ‘don’t know’
typical teenage behavior? seldom used full sentences yes, no responses unable or unwilling to cooperate with further exam annoyed and frustrated “going home”

12 After Exam Patient jumped off gurney found restroom without assistance
returned to treatment room without difficulty later found wandering in the hallway “Huh?”, “Huh?”, “Waiting for my mom” redirected to room fell asleep

13 Cousin’s History Normal state of health until 2 d PTA 2 d PTA :
arrested for possession of marijuana head banging while in cell choked??? released to custody of mother early morning not acting like self jail experience

14 Cousin’s History 1 d PTA: (first ED visit)
awoke c/o “headache” and “can’t see” sleeping ALL DAY LONG squinting and intermittently covering one eye bumping into things at home did not make sense when he talked not 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 exam teenager or pathology 2nd ED visit for same complaint change from baseline mental status sleeping a lot not 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
Cerebrovascular trauma space occupying lesion seizure related stroke hemorrhage Psychiatric psychosis severe depression Hypoxia/hypercarbia Infection meningitis encephalitis sepsis Toxic toxicity/withdrawal environmental Metabolic lytes, endocrine liver, kidney

18 Emergent Evaluation Toxicology EKG, chest xray
Pulsox, d-stick Blood Work CBC, Electrolytes, BUN/Cr, glucose LFT’s, Ca, Mg, Phos Blood Cultures ABG Head CT Toxicology urine and serum tox screen ua, micro, C&S EKG, chest xray If above negative, consider LP

19 Results All blood work is NORMAL EKG and CXR are NORMAL
Tox screen is positive for THC

20 Evaluation continues Patient instructed to get into wheelchair for head CT Patient 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 distributions left frontotemporal parietal lesion watershed between MCA and ACA

22 ED Management of Pediatric Stroke
Extrapolated from adult literature IV, O2, and monitor prevention of stroke evolution: ASA therapy anticoagulants - likely benefit if: arterial dissection, prothrombotic disorder, dural sinus thrombosis, embolic source identified thrombosis

23 ED Management of Pediatric Stroke
too late for thrombolytics CT evidence of stroke symptoms for at least 48 hours usefulness in pediatric stroke????

24 Hospital Evaluation ASA therapy MRI, MRA, MRV
echocardiogram and bubble study valves, thrombus, PFO transcranial and carotid duplex

25 Hospital Evaluation hypercoaguable studies HIV testing Lumbar puncture
PT/PTT, INR, Factor V leiden, homocysteine protein C and S, antithrombinIII anticardiolipen antibody HIV testing Lumbar puncture

26 During Hospital Course
Wernicke type aphasia visual agnosia fluent speech, poor content + circumlocutions impaired naming of visual stimuli but ok with tactile stimuli semantic paraphrasias and neologistic jargon normal motor exam

27 Outcome Etiology of stroke never identified Theory: Progress:
acute occlusion of bilateral carotids by manual pressure ? Strangled in jail Progress: continues with visual perceptual problems aphasia that interferes with his ADL’s impaired auditory comprehension

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