Hot Seat #179: An Unresponsive 7-month-old

Posted on: October 25, 2021, by :

Walter Palmer, MD

HPI: A 7-month-old ex-36 wk girl presents following an episode of altered mental status.  Patient presents with her mother, who reports that she was in her usual state of health in the morning.  While the mother was holding the patient, she became progressively more tired, and eventually became limp and unresponsive.  She denies abnormal movements and facial color change but noted the patient’s eyes had rolled backward during the event.  Despite stimulation, she remained unresponsive for 5-10 minutes.  Afterward, she vomited multiple times and was less interactive than usual.  This occurred 1 hour after feeding.

Patient arrived 3 hours after onset of symptoms, and was described as being fussy but more interactive now.  She vomits again while awaiting examination.

PMHx:

Birth Hx: Full term uncomplicated delivery

Diet: Exclusively breastfed, small amount of solid food, no supplements/vitamins

Surgical Hx: None

Medications: None

Immunizations: UTD as of 6-month visit (last given 3 wks ago)

3 episodes of “unresponsiveness with blue color change” that responded to stimulation at home, last 3 mos ago, never seen in ED, subsequently diagnosed with reflux by PMD.

Review of Systems: +Vomiting, +Altered LOC, denies fever, denies seizures, denies nasal congestion, denies shortness of breath

Exam:

VS: T 37C, HR 142, BP 108/64, R 34, 99% RA

General:  Alert.  smiling.  interacting.  playing.  Calm with parents but cries with examiner.   

Skin:  Warm.  dry.   

Head:  Normocephalic.  atraumatic.  anterior fontanelle soft and flat.  

Eye:  Pupils are equal, round and reactive to light.  extraocular movements are intact.  normal conjunctiva.   

ENMT:  Oral mucosa moist.  No pharyngeal erythema or exudate.   

Cardiovascular:  Regular rate and rhythm.  No murmur.  No gallop.  Normal peripheral perfusion.   Cap refill 1-2 sec.

Respiratory:  Lungs are clear to auscultation.  respirations are non-labored.  breath sounds are equal.   

Chest wall:  No tenderness 

Musculoskeletal:  Moves all extremities 

Gastrointestinal:  Soft.  Nontender.  Non distended.  Normal bowel sounds.  

Patient initial workup notable for: CBC with Hgb 6.6 (MCV 56), WBC 17.3 (55% neutrophils), PLT 596.  CMP with normal electrolytes, creatinine, and LFTs.  EKG as below.  UDS with +THC.  Upon further questioning, caretaker attributes this to their personal use with CBD- and THC-containing products, but reports having strict restrictions in place that do not allow for child access. At this time, she feels the child has returned to baseline.

The patient underwent head CT, which was read as normal.  Cardiology was contacted regarding her EKG and the prominent Q waves, which raised concern for LVH.  They recommended inpatient echocardiogram.  Neurology was also consulted, and they recommended inpatient EEG.

Walter Palmer
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1 thought on “Hot Seat #179: An Unresponsive 7-month-old


  1. Interesting case – the vomiting and AMS definitely had me thinking about possible intussusception off the bat.
    I think the consideration of abusive head trauma is a good one, but if I’m honest with myself, I’m not sure a head CT would be one of the first things I’d consider in an alert, playful, and interactive child. I *would* probably have an internal debate over my pre-test suspicion of an intracranial process, and I’d probably end up feeling torn over whether or not I should order it. Similarly, with no skin findings mentioned, an NAT workup may not be the first thing to come to mind, but I would certainly do a very thorough skin exam and intra-oral check to look for frenulum tears. In this age, any unusual skin findings would prompt me to get the NAT work-up – TEN-4-FACES-P anyone?

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