Case Study: Child With Altered Mental Status

EMS Report

EMS brings the patient into the assigned room and transfers her to the bed via sheet drag.

"This is Kayleigh; she's 11 years old and coming from home today. Parents report she has been 'acting strange' for a few days now, quieter than normal, and agitated yesterday. This morning they called 911 because she had a fever of 103.4° F and is now mostly nonverbal, stiff, cannot follow commands, and refusing food & drink. Baseline is talkative, alert & oriented x4. No medical history aside from being on the autism spectrum, no medications. Blood sugar normal at 105, sinus tach on the monitor at 135, 12 lead sinus tach otherwise normal, a little hypertensive at 132/86 manual, oxygen saturation 100%, respirations 24. 22g IV in the left A/C, that's all we got". Upon further questioning, you learn she also didn't react upon insertion of the IV.

History

Patient has no significant medical history. No allergies, no daily/regular medications. Mom states she gave oral suspension Tylenol this morning, unknown dose.

Family history

Epilepsy, hypertension, bipolar disorder type 2 with psychotic features, and substance use disorder. 

Exam

• Vital signs remain unchanged - (spo2 100%, pulse 130s, bp 130s/80s, rr 24-26)
• Skin is pink, warm, and profusely diaphoretic. Patient is generally rigid, staring with gaze fixed ahead, and nonverbal aside from the occasional one-word response to some questions.
• Eyes appear glassy: glossed over. Pupils are mildly dilated, equal, round, reactive to light
• Mucus membranes moist, rapid respirations noted. Lungs are clear to auscultation, bilaterally normal air entry without any stridor or wheezing. Aside from tachycardic rate, cardiac auscultation is unremarkable with no murmurs noted. Abdomen is soft and non-distended
• Deep tendon reflexes intact. When limbs are manually moved, there is slight resistance, and they retain their position after being moved

This is based on a real case with a known outcome. Some details such as names are changed for privacy compliance. Let's discuss this case study! Please provide: 

• Differential diagnosis
• Investigations with rationale
• Immediate treatment maneuvers/options
• Other treatments/options