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.
