Repeat After Me…What’s the problem here? | Case Study

[BrisketRN, BSN, RN]

The temperature outside is 97.5 or his temp is 97.5?

[SafetyNurse1968, ADN, BSN, MSN, PhD]

His temp is 97.5 (FYI, my temp is almost always 97.5). Interesting! Thought you might enjoy this, though it's a bit off topic. https://www.vox.com/science-and-health/2020/1/22/21075218/normal-body-temperature-986-fever-stanford

[VivaLasViejas, ASN, RN]

But what’s the temp outside?

[SafetyNurse1968, ADN, BSN, MSN, PhD]

Outside temp 32oF

[SmilingBluEyes]

well what are results of CBC and chem7 panels? Drug screen?

liver panel?

[Rebekka David]

On 3/10/2021 at 12:00 PM, SafetyNurse1968 said:

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.

If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Chief Complaint

The patient is a white male who states he is 25 years old. He has a deep laceration on his left knee and says, “I was running after this guy who really pissed me off, and I fell.” You notice that he mimics your behavior as you clean and bandage his wound. He occasionally repeats words you have said and loses focus, but answers questions after prompting.

History of Present Illness

You ask him if he is aware that he is mimicking your actions and words and he says, “Yeah, it’s just something I do. It kinda drives people crazy.” He says he can’t recall a time when he didn’t engage in mimicry. You ask, “Can you stop doing it if you try?” He responds, “If you try. I get all itchy and antsy…I feel better when I just do it.”. He states that he doesn’t sleep much. When you ask if he has a history of fighting, he says, “I get into fights when I have to. People make me mad, they really do.”

General Appearance 

Patient appears older than his stated age. His skin is red and rough. His clothing is dirty and mismatched, and he has dirt under his fingernails and embedded in the skin around his shirt collar and ears. He blinks repeatedly during the interview and appears agitated, especially when talking about his altercation with the man he was chasing. He has difficulty sitting still and frequently looks around the room. He sighs heavily and taps his legs with his fingers.

Past Medical History

The patient states he broke his left arm. “I was a kid. I fell out of a tree I think.” He denies any other medical or psychiatric diagnoses.

Family History

Patient is unaware of any family medical history. “I haven’t talked to my family since I left home.”

Social History

The patient states he has been homeless since he was 17 when he ran away from home. “I like it out here – it’s better for me. My parents just didn’t get me.” He admits to drinking daily. “Whatever I can get. It helps, you know?” He uses recreational drugs and cigarettes when they are available but denies addiction. He is an only child. He says he has friends who he sees around town, but no one he feels close to. He dropped out of school when he was 16.

Medications

None

Allergies

NKA

Vital signs

• BP 118/74 sitting, LA
• HR 76
• RR 16
• T 97.5^oF
• HT 5’ 11”
• WT 170 lbs

What information would help you rule out or refine a diagnosis? Remember, most healthcare facilities want to start with the least invasive and least expensive tests. For example, a CT scan usually won’t be approved before a CBC and Chemistry are done. I look forward to your questions!

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Does he have autism? 

[pmutuku]

Am really interested to know more about this case. Kindly share the results

[omoj_115, ADN, BSN, RN]

Hello everyone,

I would ask for a CBC and ammonia level. 

[guineapignurse, BSN, RN]

I would ask about his mental health history and also his family mental health history.  I would also check labs for alcohol and other drugs to rule out substance use causing the behavior. As for physical causes I would want a CBC and CMP to start. 

[SafetyNurse1968, ADN, BSN, MSN, PhD]

When the patient was picked up by the police he smelled of alcohol and blew a 0.9. After putting a few stitches in the patient’s knee, you ask for a psychiatric consult, which the patient agrees to (by the time of his consult, he is sober and still engaging in repetitive behavior). Below are other findings you might find helpful:

Review of Systems: only abnormal findings are presented:

Skin: rough and reddened, laceration on left knee

HEENT: blinks constantly

Mini mental: 29/30

Vital signs:

• BP 118/74 sitting, LA
• HR 76
• RR 16
• T 97.5oF
• HT 5’ 11”
• WT 170 lbs

Laboratory Test Results:

Negative tox screen (no recreational drugs on board)

• Mg 2.4 mg/dL (1.8-3)
• PO4 3.8 mg/dL (2.5-4.5)
• Na 140 meg/L (135-145)
• K 4.2 meq/L (3.5-5)
• Cl 109 (101-112)
• HCO3 28 mg/dL (22-32)
• BUN 20 mg/dL (8-20)
• Cr 0.8 mg/dL (0.6-1.2)
• Glu fasting 80 mg/dL (60-110)
• Ca 9.1 mh/dL (8.5-10.5)
• Hb 14 g/dL males (13.5-17.5)
• Hct 43% males (41-50%)
• Plt 320,000 cu/mm (150,000-450,000)
• WBC 7.8 x 103/mm3 (4,800- 10,800)

Repetition

The medical term for involuntary repetition or imitation of another person's actions is echopraxia - but that's not his final diagnosis. There are several disorders for which echopraxia is a symptom, though the cause or link between echopraxia and these disorders is not well understood:

• Tourette syndrome
• Autism spectrum disorders
• Schizophrenia and catatonia
• Aphasia
• Latah (a culture-bound syndrome from Malaysia and Indonesia. Those with Latah syndrome respond to minimal stimuli with exaggerated startles)
• Frontal lobe damage
• Epilepsy
• Dementia
• Autoimmune disorders

There is no formal test for a diagnosis of echopraxia. It is easier to distinguish in individuals over the age of five, because younger children frequently imitate others' actions. Babies begin copying movements soon after birth as a form of imitative learning. If the behavior continues after the age of 3, it may be echopraxia.

Echopraxia is easier to diagnose in older individuals because there are baseline behaviors to compare. Those with echopraxia report feeling an uncontrollable urge to perform an action after seeing it being performed. It is important to note that healthy adults sometimes engage in automatic behavior, for example, when a person observes someone yawning, they may yawn as well.

How would you come up with a definitive diagnosis for the underlying cause of this patient’s echopraxia? He’s also demonstrating some echolalia (word repetition)– is that significant?

[SafetyNurse1968, ADN, BSN, MSN, PhD]

FINAL POST:

After a psychiatric consult, a diagnosis of Tourette syndrome (TS) is proposed. TS is a disorder that involves repetitive movements or unwanted sounds (tics) that can't be easily controlled. For instance, you might repeatedly blink your eyes, shrug your shoulders or blurt out unusual sounds or offensive words. Once considered a rare disorder, current best estimates of the prevalence of TS hover around 1 to 10 per 10,000 of school children between the ages of 6 and 17 years old

Tics typically show up between ages 2 and 15, with the average being around 6 years of age. Males are about three to four times more likely than females to develop Tourette syndrome.

To be diagnosed with TS, a person must:

• have two or more motor tics (for example, blinking or shrugging the shoulders) and at least one vocal tic (for example, humming, clearing the throat, or yelling out a word or phrase), although they might not always happen at the same time.
• have had tics for at least a year. The tics can occur many times a day (usually in bouts) nearly every day, or off and on.
• have tics that begin before age 18 years.
• have symptoms that are not due to taking medicine or other drugs or due to having another medical condition (for example, seizures, Huntington disease, or postviral encephalitis).

Electroencephalography and structural magnetic resonance imaging are generally normal and are not clinically useful (except where there are other neurological suspicions).

“To minimize error in case ascertainment and produce an instrument measuring the likelihood of having TS, an international team of experts has recently published a TS Diagnostic Confidence Index. Scores on this Diagnostic Confidence Index are highly correlated with current tic severity, as measured by a psychometrically sound, widely used, clinician-rating scale, the Yale Global Tic Severity Scale.” (NIH, 2012) The DCI produces a score from 0 to 100 that is a measure of the likelihood of having or ever having had TS.

This patient had a DCI score of 42.

Conditions often associated with TS include:

• Attention-deficit/hyperactivity disorder (ADHD)
• Obsessive-compulsive disorder (OCD)
• Autism spectrum disorder
• Learning disabilities
• Sleep disorders
• Depression
• Anxiety disorders
• Pain related to tics, especially headaches
• Anger-management problems

The exact cause of TS isn't known. It's a complex disorder likely caused by a combination of inherited (genetic) and environmental factors. Chemicals in the brain that transmit nerve impulses (neurotransmitters), including dopamine and serotonin, might play a role.

There's no specific test that can diagnose TS. The diagnosis is based on the history of your signs and symptoms.

Risk factors for Tourette syndrome include:

Family history. Having a family history of TS or other tic disorders might increase the risk of developing TS.

Sex. Males are about three to four times more likely than females to develop TS.

The criteria used to diagnose TS include:

• Both motor tics and vocal tics are present, although not necessarily at the same time
• Tics occur several times a day, nearly every day or intermittently, for more than a year
• Tics begin before age 18
• Tics aren't caused by medications, other substances or another medical condition
• Tics must change over time in location, frequency, type, complexity or severity

There's no cure for TS. Treatment is aimed at controlling tics that interfere with everyday activities and functioning. When tics aren't severe, treatment might not be necessary.

Medication

Medications to help control tics or reduce symptoms of related conditions include:

• Medications that block or lessen dopamine. Fluphenazine, haloperidol (Haldol), risperidone (Risperdal) and pimozide (Orap) can help control tics. Possible side effects include weight gain and involuntary repetitive movements. Tetrabenazine (Xenazine) might be recommended, although it may cause severe depression.
• Botulinum (Botox) injections. An injection into the affected muscle might help relieve a simple or vocal tic.
• ADHD medications. Stimulants such as methylphenidate (Metadate CD, Ritalin LA, others) and medications containing dextroamphetamine (Adderall XR, Dexedrine, others) can help increase attention and concentration. However, for some people with Tourette syndrome, medications for ADHD can exacerbate tics.
• Central adrenergic inhibitors. Medications such as clonidine (Catapres, Kapvay) and guanfacine (Intuniv) — typically prescribed for high blood pressure — might help control behavioral symptoms such as impulse control problems and rage attacks. Side effects may include sleepiness.
• Antidepressants. Fluoxetine (Prozac, Sarafem, others) might help control symptoms of sadness, anxiety and OCD.
• Antiseizure medications. Recent studies suggest that some people with Tourette syndrome respond to topiramate (Topamax), which is used to treat epilepsy.

Therapy

• Behavior therapy. Cognitive Behavioral Interventions for Tics, including habit-reversal training, can help you monitor tics, identify premonitory urges and learn to voluntarily move in a way that's incompatible with the tic.
• Psychotherapy. In addition to helping you cope with Tourette syndrome, psychotherapy can help with accompanying problems, such as ADHD, obsessions, depression or anxiety.
• Deep brain stimulation (DBS). For severe tics that don't respond to other treatment, DBS might help. DBS involves implanting a battery-operated medical device in the brain to deliver electrical stimulation to targeted areas that control movement. However, this treatment is still in the early research stages and needs more research to determine if it's a safe and effective treatment for Tourette syndrome.

References

• https://en.wikipedia.org/wiki/Echopraxia
• https://www.mayoclinic.org/diseases-conditions/tourette-syndrome/symptoms-causes/syc-20350465
• https://www.CDC.gov/ncbddd/tourette/diagnosis.html
• Tourette Syndrome and Tic Disorders https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000195/
• Clinical Assessment of TS and Tic Disorders: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674220/