HPI: 11 mo otherwise healthy fully vaccinated male presents to the ED with concerns that he “hasn’t been acting right” for the past 3 hours. About 5 hours ago, he was left in the care of his grandparent for about an hour; however, when his mother picked her up, she noticed that he was more sleepy than usual. He was also less interested in eating and had a short episode of gagging when he was given mashed peas. His mother denies vomiting, fever, cough, congestion. His last wet diaper was 5 hours ago.

Of note, his mother mentions that he tripped and fell from standing height yesterday but cried immediately and did not have any apparent injuries. He was also diagnosed with a right AOM 2 weeks ago which was treated with 10 days of amoxicillin.

Review of Systems

Constitutional symptoms: Increased sleepiness, decreased appetite. No fevers.

Skin symptoms: No rash

Eye symptoms: No eye discharge or redness.

ENMT symptoms: No ear pain or nasal congestion.

Respiratory symptoms: No cough, wheezing or stridor.

Cardiovascular symptoms: No syncopal episodes.

Gastrointestinal symptoms: No vomiting, no diarrhea.

Neurologic symptoms: Positive for AMS

Health Status

Allergies:  No Known Allergies.

Medications: Amoxicillin

Immunizations: Up to date

Past Medical/ Family/ Social History

Medical history: No history related to chief complaint per family.

Surgical history: No history related to chief complaint per family.

Social history: Accompanied by mother. Was recently in the care of maternal grandfather; no prescriptions medications in the house. Does not attend daycare. No known sick contacts

Physical Examination

Vital signs: T 36.5C, HR 101, BP 80/63, RR 34, SpO2 100 % on RA

General:  Pt notably drowsy on exam, awakens to vigorous stimulation but falls asleep easily

Skin:  Warm.  dry.  

Head:  Normocephalic. Atraumatic

Eye:  PEERLA. Normal conjunctiva.  

Ears, nose, mouth and throat:  Tympanic membranes clear.  Oral mucosa moist.  No pharyngeal erythema or exudate.  

Neck:  Supple.  trachea mid-line.  no tenderness.  

Cardiovascular:  Regular rate and rhythm.  Normal peripheral perfusion.  Extremity pulses equal.  

Respiratory:  Lungs are clear to auscultation. Respirations are non-labored.  Breath sounds are equal.  

Gastrointestinal:  Soft. Mild generalized tenderness with HR elevation to 160s with deep palpation.  Non distended.  Normal bowel sounds.  No rebound, guarding or masses palpated.

GU: Normal GU exam

MSK: No bony tenderness, Full active range of motion throughout 

Neurological:  No focal neurological deficit observed.  Able to walk on his own, mom says a little unsteady gait from baseline.  

The patient’s mother tells you that she does not have any insurance and cannot afford “unnecessary” testing; however, she tells you that she is worried.

You order a UA, urine culture, Utox and an abdominal ultrasound. The results are normal. When you re-evaluate the patient, he continues to be notably drowsy on exam, but awakens to vigorous stimulation and has a slightly unsteady gait. His mother offers him some juice and he drinks less than an ounce before going back to sleep. His mother states that he “looks a bit better” but has to report for work in one hour. She is threatening to leave and asking you how much this visit will cost.

You convince the mother to stay for additional testing. You order point-of-care VBG, CMP, CBC, and CT Head due to the patient’s persistent somnolence. His mother agrees with the management plan. Shortly thereafter, the patient’s mother becomes irate and verbally aggressive, threatening to leave. She states that she has no other ride and does not have anyone to stay with her daughter in the ED. The ED Social Worker is consulted to assist her with transportation home. She promises to will come back to the ED in the morning when she has more time. Only the point-of-care VBG has resulted, which is shown below. He has not gotten his head CT and his CMP and CBC are pending.

POCT Source	Peripheral Blood
Whole Blood Sodium	137 mmol/L
Whole Blood Potassium	4.3 mmol/L  HI
Ionized Calcium	1.32 mmol/L
pH, Venous	7.394
pCO2, Venous	38.0 mmHg  LOW
pO2, Venous	49.7 mmHg
Hematocrit, POCT	37 % PCV
HCO3, Venous	23.2 mmol/L
Total CO2, Venous	24.4 mmol/L
Base Deficit, Venous	1
Oxygen Saturation, Venous	84.7 %  HI
Hemoglobin, POCT	12.7 gm/dL
Lactate Result (POCT)	2.10 mmol/L
Whole Blood Glucose	109 mg/dL

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