By Walter Palmer, MD; Children’s National Medical Center

HPI: 7 mo previously healthy girl presents to an outside hospital with altered mental status.  She was in her usual state of health in the morning with no recent illness.  She ate cheese for the first time around 11am, which was immediately followed by many episodes of vomiting and retching, too many to count.  She appeared tired and less interactive than usual for about 20 minutes afterward, so parents proceeded to OSH ED.

There, patient noted to be “listless” upon arrival, still with intermittent small volume emesis.  She is described as awake and tracking, and responsive to verbal and painful stimuli.  Her mental status improves after IV placement.

Initial VS: Temp 36.8C, HR 130, RR 28, BP 87/51, 100% on RA

She returns to baseline but then has another period where she “lacks focus and has decreased muscle tone.”  No witnessed eye deviation, no abnormal movements, responsive.  VS remain unchanged. The episode resolves spontaneously after 5-10 minutes.

Labs: Normal electrolytes and glucose, RVP negative, CBC with normal Hgb/Wbc/Plt, Utox and UA pending.

Imaging: Normal CXR.

Patient transported to CNMC ED without further issues.

Exam: VS essentially unchanged from prior

Gen: Patient playful, laughing, no acute distress

Neuro: AF flat, atraumatic, tracking appropriately, PERRL, no nystagmus, normal and equal distal muscle strength

Resp: CTAB, breathing comfortably

CV: RRR, no murmur, normal peripheral perfusion

GI: Soft, nondistended abdomen

GU: Normal genitalia for age

EKG performed and normal for age. On further questioning, the patient has never had cheese before, but has tolerated breast milk (from a mother who consumes dairy products occasionally) and Enfamil formula without issues.  No history of loose or bloody stools, no known allergies.

Head CT deferred given her reassuring mental status and exam.

Patient is able to take a bottle of breast milk normally without issues, then falls asleep on a monitor and maintains normal VS.