Case of a 16 Year Old Male That “Can’t See, Can’t Hear”
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Case of a 16 Year Old Male That Case of a 16 Year Old Male That “Can’t See, Can’t Hear”“Can’t See, Can’t Hear”
Teresa M. Carlin, MDAssistant Professor
Department of Emergency Medicine and PediatricsJohns Hopkins University
Baltimore, MD
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Teresa Carlin, MD
Case PresentationCase 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
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Teresa Carlin, MD
Case continuedCase 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
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Teresa Carlin, MD
HistoryHistory
• Source: per patient • CC: can’t see and can’t hear– could not elaborate further
• ROS:– denied recent illnesses– denied nausea, vomiting, diarrhea– denied fevers, chills, URI– denied rashes– occasional headache
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Teresa Carlin, MD
HistoryHistory
• PMH/PSH: unremarkable• Medications: none• Allergies: none• SH: – has one child– lives with mom– occasional ETOH and marijuana– denied other illicit drugs
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Teresa Carlin, MD
ExamExam
• Bright and alert
• walked into the treatment area without difficulty
• VS: 37.5*C, HR=72, BP=130/70, and RR=14
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Teresa Carlin, MD
ExamExam
• HEENT:– EOMI and without nystagmus–muddy sclerae– pupils mid-sized and reactive– TM’s normal bl
• NECK:– supple– no adenopathy– no bruits
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Teresa Carlin, MD
ExamExam
• CV:– regular rate and rhythm–no murmurs, rubs, or gallops–nondisplaced PMI
• RESP:–CTA–unlabored
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Teresa Carlin, MD
ExamExam
• 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
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Teresa Carlin, MD
ExamExam
• 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
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Teresa Carlin, MD
ExamExam
• 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”
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Teresa Carlin, MD
After ExamAfter 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
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Teresa Carlin, MD
Cousin’s HistoryCousin’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
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Teresa Carlin, MD
Cousin’s HistoryCousin’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
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Teresa Carlin, MD
SummarySummary
• 17 yo male not acting right– 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
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Teresa Carlin, MD
Questions?Questions?
• What is the differential diagnosis?
• What initial laboratory tests should be drawn?
• What ancillary studies should be ordered?
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Teresa Carlin, MD
Altered Mental Status Altered Mental Status Common CausesCommon Causes
• Infection– meningitis– encephalitis– sepsis
• Toxic– toxicity/withdrawal– environmental
• Metabolic– lytes, endocrine– liver, kidney
• Cerebrovascular– trauma– space occupying lesion– seizure related– stroke– hemorrhage
• Psychiatric– psychosis– severe depression
• Hypoxia/hypercarbia
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Teresa Carlin, MD
Emergent EvaluationEmergent Evaluation
• 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
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Teresa Carlin, MD
ResultsResults
• All blood work is NORMAL
• EKG and CXR are NORMAL
• Tox screen is positive for THC
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Teresa Carlin, MD
Evaluation continuesEvaluation 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?
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Teresa Carlin, MD
Head CT ResultsHead CT Results
• Head CT/MRI are ABNORMAL–bilateral watershed strokes• between MCA and PCA distributions
– left frontotemporal parietal lesion• watershed between MCA and ACA
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Teresa Carlin, MD
ED Management of Pediatric StrokeED 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
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Teresa Carlin, MD
ED Management of Pediatric StrokeED Management of Pediatric Stroke
• too late for thrombolytics– CT evidence of stroke– symptoms for at least 48 hours– usefulness in pediatric stroke????
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Teresa Carlin, MD
Hospital EvaluationHospital Evaluation
• ASA therapy
• MRI, MRA, MRV
• echocardiogram and bubble study– valves, thrombus, PFO
• transcranial and carotid duplex
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Teresa Carlin, MD
Hospital EvaluationHospital Evaluation
• hypercoaguable studies– PT/PTT, INR, Factor V leiden, homocysteine– protein C and S, antithrombinIII– anticardiolipen antibody
• HIV testing
• Lumbar puncture
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Teresa Carlin, MD
During Hospital CourseDuring 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
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Teresa Carlin, MD
OutcomeOutcome• 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 ADL’s– impaired auditory comprehension