By Dr. Erin Thomas, INOVA Children’s

HPI:

A 15-year-old previously healthy girl presents with intermittent right facial numbness, difficulty speaking and left arm weakness for the past 3 days. Episodes last about 10 seconds. Also complaining of persistent headache for the past 5 days, with associated nausea and photophobia. On evening of presentation vomited x3, last episode was blood-tinged. Denies head trauma, weight loss, fever, changes in vision, dizziness, or syncope.

ROS:

+abdominal pain, vomiting, headache, photophobia, weakness. Otherwise negative.

PE:

Vitals: HR 88, BP 103/67, RR 24, SpO2 100%, Temp 99.3F, Wt 18.6 kg

General: awake, alert, well appearing

Eyes: PERRL, EOMI, no conjunctival injection or discharge

Heart: RRR, systolic murmur 2/6

Resp: clear to auscultation bilaterally

Neuro: age-appropriate behavior, symmetric facial movements, follows commands, CN 2-12 grossly intact, no focal deficits

Labs/Rad:

CT head w/o contrast: no evidence of acute intracranial abnormality

Given Zofran and Tylenol with improvement in headache and nausea. Neuro exam remains normal.

She was discharged home with Zofran as needed and instructed to follow up with Neurology within the week.

6 days later, she returns to the ED with altered mental status and left arm weakness. Since discharge, has had intermittent fever with waxing and waning left sided weakness. Today, she has new onset altered mental status and left sided weakness all day and has been unable to speak.

PE:

Vitals: HR 114, BP 135/73, RR 18, SpO2 99%, Temp 102.2F

General: not distressed but clearly altered, says “mom,” but uses no other words

Head: atraumatic, normocephalic

Eyes: no photophobia, PERRLA, unable to assess extraocular motions

Neck: normal ROM, non-tender, no meningismus

Resp: clear to auscultation, no respiratory distress

Heart: RRR, no murmurs

Neuro: unable to assess gait, AxO x0, follows few basic commands, +left sided facial droop, LUE strength 4/5, RUE strength 5/5, unable to assess lower extremity strength, unable to assess CN

Skin: warm and dry, no rash

Labs/Rad:

CBC: WBC 9.29, Hgb 6.5, Hct 20.3, Plt 13

CMP: Glu 139, BUN 11, Cr 0.9, Na 135, K 3.7, Cl 012, CO2 21, AST 42, ALT 13, Alk Phos 97, Bili 2.2

CRP 1.8, ESR 78

LDH 1491

Uric Acid 9

PT 14.3, INR 1.1, PTT 28, Fibrinogen 395

MRI Brain with/without contrast: limited exam due to presence of metallic orthodontic hardware, within those limitations, evaluation of the brain is within normal limits

Given significant anemia and thrombocytopenia, decision made to defer LP. Given ceftriaxone.