Can you guess the DX of this patient? - page 2

Ok ladies and Gents, try this one on for size. See if you can correctly guess what is wrong with the patient before the Doctors finally figure it out! Real Life scenario: 17 y.o.w.f. presents to... Read More

  1. by   Mabaso
    From the problems mentioned here, I can loosely say that it is possible that the pt has narcolepsy. Her age is tender for such.
    thank you!
  2. by   HyperRNRachel
    Quote from catrn10
    Ok ladies and Gents, try this one on for size. See if you can correctly guess what is wrong with the patient before the Doctors finally figure it out!


    Real Life scenario: 17 y.o.w.f. presents to her GP's office with her mother, a disabled former ICU Nurse. Her complaint is "constant headaches in the back of my head that get worse sometimes." Her past history is significant for Asthma, Viral meningitis at 5 mo., spinal shock from a riding accident at 9 yrs. With no residual problems, MVA 8/03 wt. LOC, intubation at the scene, final DX of "severe concussion and brain bruise" She was subsequently treated for head and neck pain by injection of a block for 4 months afterward. She was involved in another MVA two weeks after the first and "hit my head", but did not seek treatment as "it was only a little bump". She also relates that she experiences sharp pains over her left temple "sometimes". The Mother reports that she has not "acted quite right" since she was involved in the car accident August 2003. The patient agrees, but is unable to explain exactly what has changed. The mother reports the daughter is moody and cries frequently. She states she is sleeping or sleepy most of the time, is forgetful, and cannot concentrate. The daughter denies feeling depressed, but cannot describe how she does feel. Drug screen is negative. A diagnosis of depression is made.
    The patient returns to the office several weeks later. The Mother states that the daughter is unimproved; in fact, she has had an episode that appeared to be a panic attack, hyperventilated, was unable to answer questions, and moved her limbs in a stiff manner. The Mother emphasizes that there was "something not quite right about it, it didn't really seem like a panic attack, but that is the closest thing I can compare it to other than a seizure of some kind." The daughter reports she can "feel it coming on" The anti-depressant is changed and an anti- anxiety med is added to take when she": feels a spell coming on". The mother also relates that counseling was not helping as her daughter felt the therapist "sucked". The mother, who had been present during 2 sessions, related that the therapist appeared " to have untreated ADD". Another referral is made.
    One month later, the patient presents with added symptoms of visual disturbances and I creased "panic attacks" The mother reports that the daughter had called her twice in one day while she (the mother) was out of town attending a funeral. In the first call, the daughter was oddly euphoric, in the second call, her daughter was very distressed and reported "seeing things, like I am close to something, but when I blink I am farther away than I thought". The boyfriend was called by the mother (as no one else was available) and asked to go check on the daughter. Upon arrival, he called the Mother, telling her the daughter was "having another attack." Not knowing what to do, he gave the daughter several puffs on her inhaler and a transene. He reported that she was now asleep, but her torso and arms turned "Kinda red." He reported that it had faded and she was breathing fine now. The mother drove across two states to get home. The anti-depressant, Effexor, is increased.
    3 months later the mother calls requesting the daughter be seen immediately for possible seizure activity. An appointment is made that day and the daughter is brought in. The patient reports that she is having periods were she doesn't know what happened and friends have had to yell at her several times to get a response. She reports that her vision "does like a bugs-bunny cartoon at the end, only porky pig isn't in the middle of the black thing and it goes back and forth. " She reports numbness and tingling in her fingers during attacks. The patient is sent for a MRI of the head and neck and referral is made to a neurologist. The Neuro Doc orders an EEG. And guess what was found. Seizure activity. The patient is placed on Lamictal. Headaches and "attacks" diminish and stop within 1 week. The patient is now fine.
    Now how bad do You think I feel for letting this go on for so long before I figured it out? Real bad.... Guess it's a good thing I'm retired now. To give myself a break, I will say that the kid hid most of what was going on with her because she thought she was going insane. I felt so bad for her.
    Do not beat yourself up; you were going by incomplete information. Leave out a puzzle piece, even if it is just one piece, and you do not have the complete picture. And another thing, why did it take the MD's so long to come up with a diagnosis? Definitely not your fault, because it appears that even if you did not think about seizures as a diagnosis you knew the diagnosis was not depression! Good for you for having an active role in encouraging the family to get answers.
  3. by   catrn10
    Mom WAS there all along. But the child was hiding important symtoms because she thought she was going insane. She thought she was going to end up in a nut house. I could only tell what I knew and observed. As she rarely spends time at home,(she is VP of the student council, editor of the school news paper, on the County Youth Committee as VP, homecoming court, etc.) I didn't see much. Only when she had a crisis would she let me in on another little piece of info. I have never been so frustrated in my life and I have never seen a seizure like the ones she had. Very sutle stuff, especially since she has ADD. In retrospect, it seems so obvious, but the day to day was quite different. She would even lie about having the headaches. She would say they were gone. The symptoms got progressively worse, ie more frequently, as time progressed. I have never dealt with this type of seizure before now. Most of the time, it appeared to just be an ADD moment. The "bigger" ones didn't look or act like any I had ever seen. I still have trouble describing them. The word dystonia comes to mind, but even that doesn't quite fit. Plus, since she thought she was going crazy, she would become hysterical, crying and begging for me to help her, and saying she didn't want to go to the "Valley"( the local mental hospital). It was heartbreaking. Then it would blow over and everything would appear to be okay and she would refuse to discuss it and lie and say she was fine. Then BLAM! off we'd go again. She has a twin sister, I am involved in a Worker's Comp. thing and I had a total hip replacement, carpal tunnel surgery, was bedridden most of the time in pain and a mental breakdown during the same period of time. I probably wasn't at my most observant. I just wanted to see if anyone else came up with the answer any faster than the Docors and me.
  4. by   catrn10
    Oh yeah, I forgot to mention that I was not worried about a tumor as she had CT scans post MVA that were negative for everything except the "Brain Bruise" (The report actually said that":
  5. by   catrn10
    And Oh but she had had a Neuro consult, right after the accident. He is the one who gave her the nerve blocks and she lied and said they had worked. Teenagers can go to extraordinary lenghts not to be different and this kid is the Queen of denial.
  6. by   leslie :-D
    i initially guessed seizures until i read about the visual hallucinations and her flank areas turning red.

    but i too am perplexed as to why her mother did not bring her to a neurologist in the first place, given dtr's hx.

    leslie
  7. by   begalli
    Quote from catrn10
    Teenagers can go to extraordinary lenghts not to be different and this kid is the Queen of denial.
    Very true about teens feeling the need to fit in. It's a developmental thing.

    Do you think she was the "queen" of denial to fit in or was she just really really scared. She sounds like an otherwise good kid. I think you're feeling manipulated by her, but I don't think she can be blamed for that. By the way you describe her bahavior, she was obviously terrified.

    It just kind of bugs me that this teenager is being called a liar and queen of denial when FINALLY after being mis-diagnosed and being told that she had a mental illness (basically to her - it's all in your head) and after suffering for a period of time she's diagnosed with SEIUZURES.

    Or maybe I'm misunderstanding.
    Last edit by begalli on Mar 13, '05
  8. by   begalli
    Quote from catrn10
    I have never dealt with this type of seizure before now. Most of the time, it appeared to just be an ADD moment.
    And what is just an ADD moment?

    I have a daughter recently diagnosed with adult ADD. "Moments" are 24/7. And the moments are a way of life. :stone
  9. by   summersbreeze
    I have not even begun nursing school yet, but the first thing that came to my mind was that the doctor should have took the girls medical history into account, and ordered an MRI from the beginning. I cannot see that the mother is at fault in this situation. I know from experiance that things can show up long after an accident, and the doctor should have know this as well. The headaches in themselves should have put up the alert sign for him.
  10. by   zenman
    Bladder meridian need some work!
  11. by   FranEMTnurse
    Quote from nanna4
    Sad but seems to be not so unusual for depression to be diagnosed too quickly. Many medical conditions have side effects that include depression, and I just wish more docs would investigate the CAUSE!!! of the depression instead of treating just the depression.

    I was recently diagnosed with plain ole' hypertension, but only after going to 3 dif. docs in a week. Because my numbers "weren't that high" and I c/o being very tired with poor sleep I had a hard time getting anybody to listen to me. I told them my b/p was running 30 points higher than what was normal for me, but couldn't get any help until I saw an awesome PA who treated me appropriately, and SURPRISE!!! I got up this morning feeling like life is again worth living. Just wish the first docs had the decency to pay attention to what I was telling them. could have saved me alot of time/trouble/money. Sorry if I sound a little too heated...I'm still upset.
    I know the feeling all too well. My own doc's like that. If it's within normal standardized limits, or if it doesn't show up in test results, then there's something wrong with you mentally. It's sooooo frustrating! I say the Nurse Practitioners and the PAs are far more thorough than the docs, who mostly have the attitude, "you're just another number to help provide for my income" are. Okay, I'm getting too hot here too. I better go.
  12. by   catrn10
    I didn't call her a liar, I said she lied about not having symptoms and denied, to me and herself what was really going on. At least that was what I was trying to say. She is a good kid and had not been prone to lying in the past. Which is why I accepted at face value what she told me.And yes, she was terrified- thus the lying and denial. And for those of you who did not understand or simply did not read it. I, her mother, did request a referral to a Neurologist at first. She went and was diagnosed with migraines and neck pain due to the 2 MVA's she had. She didn't even mention 3/4 of her symptoms until much later, as a matter of fact, she denied (or lied about them) when asked. I honestly did not know this would turn into a character assasination of my parenting skills when I posted this. The post was meant to point out how difficult it can be to correctly evaluate a teenager, especially when they are not exactly forthcoming with information. And it all was so subtle. In my defense, I have been fighting severe pain, loss of income and lifestyle due to a worker's comp accident. I was suicidal at one point.(I am fine now, depression wise, thanks to medication and counseling). I have 2 other kids at home (11 and 17), my oldest, married daughter got pregnant and sick during the same time period, and I had to keep my 2 year old grandson for several months. Plus I had 2 surguries, and was bedridden for nearly a year. I walk with a cane, need both knees replaced, and still need surgury on the other hand for carpel tunnel. Oh, and and this child had no less than 3 MVA's where she was the driver, and one where she was a passenger. And the car wrecks were not due to seizures, it was due to carelessness. And my husband got laid off permanently and had to find a new job, which took a year, during which we had no insurance and did not qualify for welfare. I imagine she also kept a lot to herself because she knew we didn't have any insurance or money. It's a wonder I noticed anything at all with all that happened..and I guess my assessment skills are rusty. And about the ADD moment, she was diagnosed with ADD at age 7. She had extensive testing done at that time. She did not have the hyperactivity problem, she would just space out. She was checked for seizure activity at that time and was normal. We worked with her and thanks to medication, diet and behavior management, she adapted and did well enough to go off her medicine. I mentioned to the Doctors that it was as if her ADD had returned full force and was told that with the stress of her senior year, etc. that it was not uncommon for the ADD to become worse. It seemed to make sense at the time. And the medication she was placed on was supposed to treat ADD and depression.
    Last edit by catrn10 on Mar 14, '05
  13. by   FranEMTnurse
    Quote from catrn10
    I didn't call her a liar, I said she lied about not having symptoms and denied, to me and herself what was really going on. At least that was what I was trying to say. She is a good kid and had not been prone to lying in the past. Which is why I accepted at face value what she told me.And yes, she was terrified- thus the lying and denial. And for those of you who did not understand or simply did not read it. I, her mother, did request a referral to a Neurologist at first. She went and was diagnosed with migraines and neck pain due to the 2 MVA's she had. She didn't even mention 3/4 of her symptoms until much later, as a matter of fact, she denied (or lied about them) when asked. I honestly did not know this would turn into a character assasination of my parenting skills when I posted this. The post was meant to point out how difficult it can be to correctly evaluate a teenager, especially when they are not exactly forthcoming with information. And it all was so subtle. In my defense, I have been fighting severe pain, loss of income and lifestyle due to a worker's comp accident. I was suicidal at one point.(I am fine now, depression wise, thanks to medication and counseling). I have 2 other kids at home (11 and 17), my oldest, married daughter got pregnant and sick during the same time period, and I had to keep my 2 year old grandson for several months. Plus I had 2 surguries, and was bedridden for nearly a year. I walk with a cane, need both knees replaced, and still need surgury on the other hand for carpel tunnel. Oh, and and this child had no less than 3 MVA's where she was the driver, and one where she was a passenger. And the car wrecks were not due to seizures, it was due to carelessness. And my husband got laid off permanently and had to find a new job, which took a year, during which we had no insurance and did not qualify for welfare. I imagine she also kept a lot to herself because she knew we didn't have any insurance or money. It's a wonder I noticed anything at all with all that happened..and I guess my assessment skills are rusty.
    Some of us are not attacking you. I know I'm not. And as far as your teenage daughter goes, kids do those things because they want to be like all the other teens. We all go through these anxious times in one way or another. I felt like she feels when I was going through menopause. I had no idea what was happening to me. I would burst out crying, I got so grouchy at times, I hated myself, and even questioned my inability to control the mood, and I was depressed for three long years, and didn't know why. I had a peaceful homelife, I had my own home which was paid for, I was out of debt with the exception of my car payment, and I was a well respected community servant. What I once found joy in doing, seemed mediocre, etc. So please, accept our messages, at least some of our messages as to only trying to help.

    I sincerely feel for you.:icon_hug: The most difficult job in the world is parenting. And I too am disabled. You don't need to defend yoursel for your actions. You did what you thought was best for your daughter. I sincerely wish you a good outcome with this.

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