Case of a 16 Year Old Male That Cant See, Cant Hear - PowerPoint PPT Presentation

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Case of a 16 Year Old Male That Cant See, Cant Hear

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Case of a 16 Year Old Male That 'Can't See, Can't Hear' Teresa M. ... several tatoos on arms and back. Extremities: well perfused, no edema. Teresa Carlin, MD ... – PowerPoint PPT presentation

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Title: Case of a 16 Year Old Male That Cant See, Cant Hear


1
Case of a 16 Year Old Male That Cant See, Cant
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 cant 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 cant see, cant hear
  • triage assessment
  • normal vital signs
  • grossly normal vision
  • grossly normal hearing

4
History
  • Source per patient
  • CC cant see and cant hear
  • 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 37.5C, HR72, BP130/70, and RR14

7
Exam
  • HEENT
  • EOMI and without nystagmus
  • muddy sclerae
  • pupils mid-sized and reactive
  • TMs normal bl
  • NECK
  • supple
  • no adenopathy
  • no bruits

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

9
Exam
  • Abdomen
  • 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 dont 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
Cousins 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
Cousins History
  • 1 d PTA (first ED visit)
  • awoke c/o headache and cant 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
  • headache
  • cant see, cant 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
  • Pulsox, d-stick
  • Blood Work
  • CBC, Electrolytes, BUN/Cr, glucose
  • LFTs, Ca, Mg, Phos
  • Blood Cultures
  • ABG
  • Head CT
  • Toxicology
  • urine and serum tox screen
  • ua, micro, CS
  • 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
  • thats what he has been doing
  • he aint 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
  • 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
  • acute occlusion of bilateral carotids by manual
    pressure
  • ? Strangled in jail
  • Progress
  • continues with visual perceptual problems
  • aphasia that interferes with his ADLs
  • impaired auditory comprehension
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