ERDoc Posted November 25, 2006 Posted November 25, 2006 It's been a while since I have had a case worthy of becoming a scenario, but finally I have one for you all. You are called to the home of a 15 y/o male whose parents called because they noticed he couldn't remember anything. The pt is denying any headache and offers no other complaints. The scene is safe and the parents are with the pt and visibily upset. What history do you want to know?
MeekoBB Posted November 25, 2006 Posted November 25, 2006 Medical hx, medications, does he play sports, and if so, recent head injuries?
ERDoc Posted November 25, 2006 Author Posted November 25, 2006 Medical hx, medications, does he play sports, and if so, recent head injuries? PMH significant for asthma, but has not used his MDI in several years. Other than the MDI he doesn't take anything. He is on his school's soccer team. The pt isn't sure, but doesn't think he hit his head. The father says that the coach called a little while ago and said that while the pt was at practice today he was running down field and suddenly veered off to the sideline. When the coach asked him what was wrong the pt looked kind of blank and said he wasn't sure. The coach had him sit out the rest of practice. The coach did not see him hit his head at all. After practice the coach asked him what happened and the pt could not remember.
MeekoBB Posted November 25, 2006 Posted November 25, 2006 vitals? i'd suspect something with the brain of course..... cva/tia maybe? without any signs or suspician of trauma, it would have to be organic. Also, any relatively new traumatic EVENT, loss of someone, or other type of accident?
itku2er Posted November 25, 2006 Posted November 25, 2006 no HX of seizures diabetic since trauma wasnt a factor it has to be medical..... any trauma in the last few days? and any chance he might be doing drugs?
ERDoc Posted November 25, 2006 Author Posted November 25, 2006 The parents deny any h/o diabetes or seizures. There is no recent head trauma that the parents can recall. The pt denies drug use, even after the parents leave the room. They say he is a straight A students and doesn't hang out with the kind of kids that use drugs. There are no trauatic events that the parents are aware of. We will get to VS and PE once we have completed the history. Is there anything anyone else wants to know about the history. For the record, this happened in late September (if that makes a difference to anyone).
vs-eh? Posted November 25, 2006 Posted November 25, 2006 You are called to the home of a 15 y/o male whose parents called because they noticed he couldn't remember anything. What exactly does this mean? Short term (i.e. items to recall after 5 mins)? Long term (can't remember certain past events he could before)? Selective (can remember his birthday at times)? Any pattern to this memory loss? Events? Environments? Any other noted "balance problems" or issues of him appearing "absent" or "starring into space"?
ptemt Posted November 25, 2006 Posted November 25, 2006 How are his pupils presenting? Hitting a soccer ball with your head can have a cumulative effect.
itku2er Posted November 25, 2006 Posted November 25, 2006 The parents deny any h/o diabetes or seizures. There is no recent head trauma that the parents can recall. The pt denies drug use, even after the parents leave the room. They say he is a straight A students and doesn't hang out with the kind of kids that use drugs. There are no trauatic events that the parents are aware of. We will get to VS and PE once we have completed the history. Is there anything anyone else wants to know about the history. For the record, this happened in late September (if that makes a difference to anyone). straight a students use drugs too........ any blurred vision or spots in the eyes double vision any visual changes at all? Does he remeber what you talked about when asked again? any hx of this happening before any recent infections
Fifthkid Posted November 25, 2006 Posted November 25, 2006 hx of asthma, is pt on allergy meds rx or otc? I know you said none in hx but not bad to ask again ear infections? tick bites? not sure region but other types of insect bites?
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