tommyk
04-09-2006, 03:49 AM
A 5-month old baby named Kevin Costner is brought to a pediatrician's office because of increased lethargy and irritability. You note a few purpura over parts of his body. The parents state that the child rolled off the couch and fell on the floor one day prior to presentation. His parents report that the child has been previously healthy and is up to date on his vaccinations. He has been meeting his development milestones. His fontanelles are full. While in office the patient develops a tonic clonic seizure. Very good but HARD question: What do you give to the patient???:confused: :confused:
1-CT Scan of the Head
2-Examine the retina
3-Serum ammonia levels
4-Benzodiazepines for the seizures
5-Lumbar Puncture
6-Reassurance & appointment in one week.
7-Consult Neurosurgery
a)The child's story is worrisome for shaken baby syndrome, in which the symptoms may not correlate with the physical findings. This diagnosis should be considered in any infant presenting with a dissonant history suspicious of child abuse. The child's fontanelles are full, indicative of increased intracranial pressure. A retinoscopic examination will indicate if this is indeed the case, since blurred fundi would suggest increased pressure. A retinoscopic examination can be done faster than a head CT.
The patient may ultimately need a head CT but the eye examination should be done first.
Ammonia levels should be checked if hepatic encephalopathy is a consideration.
Benzodiazepines (or another anticonvulsant) may be needed in the short term to stop the seizure, but it is important to determine the cause of the seizure before intervening
Because the patient has increased intracranial pressure (suggested by the full fontanelles), a lumbar puncture may cause uncal herniation and should be avoided!
If you picked reassure, you are dead wrong.
1-CT Scan of the Head
2-Examine the retina
3-Serum ammonia levels
4-Benzodiazepines for the seizures
5-Lumbar Puncture
6-Reassurance & appointment in one week.
7-Consult Neurosurgery
a)The child's story is worrisome for shaken baby syndrome, in which the symptoms may not correlate with the physical findings. This diagnosis should be considered in any infant presenting with a dissonant history suspicious of child abuse. The child's fontanelles are full, indicative of increased intracranial pressure. A retinoscopic examination will indicate if this is indeed the case, since blurred fundi would suggest increased pressure. A retinoscopic examination can be done faster than a head CT.
The patient may ultimately need a head CT but the eye examination should be done first.
Ammonia levels should be checked if hepatic encephalopathy is a consideration.
Benzodiazepines (or another anticonvulsant) may be needed in the short term to stop the seizure, but it is important to determine the cause of the seizure before intervening
Because the patient has increased intracranial pressure (suggested by the full fontanelles), a lumbar puncture may cause uncal herniation and should be avoided!
If you picked reassure, you are dead wrong.