Can you guess the DX of this patient?

  1. 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.
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  2. 27 Comments

  3. by   DidiRN
    I always hate it when i hear stories like this...everything should be ruled out medically before assuming it's depression or some kind of psych disorder.
    Sorry to hear about this.
  4. by   begalli
    Quote from catrn10
    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.
    Yes, ABSOLUTELY give yourself a break. I mean this genuinely and with all sincerity.

    But this is not the child's fault either. Unless it's just not mentioned, she should have had an MRI earlier. She had a lot going on....even a lot for an adult to describe.

    I felt so bad for her.
    I echo your sentiments.
  5. by   rjflyn
    Sadly patienta can have seizures for quite sometime. Until someone sees something or the patient reports something that would make you think seizures they can get missed. I read the post a couple times and to start I thought a tumor or brain abcess.

    Rj
  6. by   ~Kitty~
    I was thinking IICP. Could that be a factor?
    Sorry to hear all that.
  7. by   Cassinia
    Being an oncology nurse for so long, the first thing I thought about was a brain tumor, until I got further into the descriptions. Next, I thought about seizure activity of some type.

    I agree with the others about why did it take so long for a MRI or neurologist consult to be done.

    But, where was mom? If she's an ex-ICU nurse, why wasn't she insisting on a neuro consult or scan? I know if that was my child, after the first failure of the medication therapy, I would be demanding scan and/or consult.
  8. by   lil' girl
    We were taught that many children have these kind of episode's. Seizures but no one knows about them, but that they are constantly being dx with ADD. It is terrible that it took so long to find out the root of the problem, but don't blame yourself.
  9. by   Tweety
    I'm glad to you she's better now. Give yourself a break. Sounds like you've through hell and back with her. You've been there for her. Don't beat yourself up, you were at the mercy of the MD's. These kinds of seizures with behavior manisfestations are hard to diagnose.

    Best wishes that things continue to improve.
  10. by   FranEMTnurse
    I guessed seizures immediately, probably r/t the head injuries (concussions?), & whiplash. I have seen people in all stages of seizures. My daughter's friend and classmate had a petit mal seizure when she was in my home. At first, I thought she was ignoring me when I was talking to her. But when she came out of it, I knew. She is an epileptic. The family doesn't know the cause.

    I have seen people in grand mal seizures where in fact one girl on my bus got out of her seat and began walking around in the aisle in circles. I pulled the bus to the side of the road, sat her in a seat, leaned her head up against the window with her jacket for a pillow, and buckled her in. I then went to her house immediately, asked the oldest passenger to go get her mom, and then I relayed the information to the mom. I escorted her off the bus, handed her to her mom, and she was absent from school the following day. Turns out the girl had a brain tumor, and had seizures very often.

    The first one I witnessed, was when I was a child. I saw a man grab towels off a shelf, then throw them all over, then he collapsed on the floor. Scared me silly!

    I also had a patient one time on the ambulance, who went into status epilepticus. Turns out she had 2 things wrong with her. She had Wilsons disease of her heart, and a brain tumor. She was a mom of 2 little tykes. She said she could feel them coming on also.

    And lastly, I myself had grand mal seizures years ago. Spinal memingitis was going around in our area then, so the docs thought I had that. They placed me in a private room next to a boy who was in an adjoining room with it. I was later diagnosed with viral encephalomengitis at Columbia Medical Center Neurological institute in NYC.
  11. by   carvanaragon
    it is really sad that the diagnosis was missed. the fact that there was a history of head trauma more so with loss of consciousness, the MD should already had in mind the possibility of post traumatic seizures. if the simple diagnostic eeg would have been done earlier it would have been correctly diagnosed early. seizures are treatment specific, so there is no room for doubts.

    another thing is that why were psychiatric conditions the initial considerations without the benefit of other diagnostics? anxiety and depression should only be considered when all other diagnostic procedures proved essentially normal.

    it feels bad to hear stories like this happen in a country where advance diagnostics are readily available at hand.
  12. by   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.
  13. by   ERNurse752
    Quote from Cassinia
    Being an oncology nurse for so long, the first thing I thought about was a brain tumor, until I got further into the descriptions. Next, I thought about seizure activity of some type.

    I agree with the others about why did it take so long for a MRI or neurologist consult to be done.

    But, where was mom? If she's an ex-ICU nurse, why wasn't she insisting on a neuro consult or scan? I know if that was my child, after the first failure of the medication therapy, I would be demanding scan and/or consult.

    The original poster is the mom, I believe.
  14. by   ERNurse752
    Don't beat yourself up...you said yourself she wasn't giving up all the information b/c she thought she was going crazy. I also think it's really hard to be objective and clinical in our thinking when it's a family member and not a patient who is a stranger to us. Hope things continue to get better!

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