Case Study: Child With Altered Mental Status

In this Case Study, an 11-year-old child with autism presents by ambulance to the children's hospital with altered mental status, bizarre behavior and fever. With this case, I hope to bring some interesting discussion among nursing colleagues & students. Specialties Pediatric Case Study

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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

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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ErikWeeWoo

About ErikWeeWoo, BSN, RN, EMT-P

Erik has 10 years of varied nursing & paramedic experience in settings including prehospital, emergency, ICU, behavioral health, and child welfare.

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Specializes in ER, Hospice, PEDS,Teaching, Rehab, Critical Care.

Differential diagnoses: all fever origins such as UTI, Pneumonia, although the lungs sounds we're CTA and good oxygenation, bacteremia, meningitis, gastroenteritis, accidental OD and medication induced hyperthermia (such as risperdal), post ictal from SZ

Needs a full w/u: IV, cbc, cmp, crp, procal, blood cx, lactate, CXR, UA, UDS, LP, full med list eval, immunization info, allergy info, maybe a CT or KUB if none of the other imaging studies reveal anything and further evidence of GI/GU sx are found. 

Immediate treatment includes continuing assess and reeval of airway protection, breathing and oxygenation, antibiotic admin, LP ASAP, and all other mentioned above, orders for admission.  

If I had to jump right on a Dx I might say meningitis.

 

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The first thing that came to mind was meningitis as well. The previous RN's expertise on testing shows much more experience that I have but was wondering because there was no mention of neck stiffness or a seizure but maybe I missed that. Not  everyone's symptoms are the same. Perhaps a spinal tap would be in order and  hopefully  would reveal something. 

If it is not, I was wondering if if could be Serotonin syndrome? No mention of what mother takes. Perhaps the mother is on anti-depressants and the young girl took multiple pills. I am curious why mother didn't know how much tylenol she gave her child but mother's anxiety probably got the best of her. 

 I agree that the hyperthermia (NMS) could be caused by  anti-psychotics or  promethazine that the child took from mother's medications?

All of these are just a guess but thanks for the interesting case study!   

Serotonin syndrome.docx

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