Age: 0.17
Sex: M
Vaccine: DTPPVHBHPB, UNK, UNK
Symptoms: Magnetic resonance imaging head abnormal, Magnetic resonance imaging spinal abnormal, Malaise, Pain, Partial seizures
Clinical narrative: Summary from Medical Records 1. On Tuesday, Jan. 23, 2024, patient was cleared for bronchiolitis by his Primary Care Physician (PCP) but proceeded to vomit yellow fluid 3 times during the subsequent overnight period with vomiting NOT occurring with feeds. Mom reported that patient was fussier through that night. 2. On Wednesday, Jan. 24, 2024, patient was brought back to his PCP for vomiting at which time routine recommendations were made. Mom reported that patient was acting ?lethargic? and not wanting to take formula, but did take 4 oz of ?hydration drink.? As per medical records reported by Physician, ?Mom reported that patient was fussier throughout Wednesday night, he was hard to consoled (sic) but eventually consoled for dad. Mom reported that patient acted like he was in pain and did not sleep well.  3. Thursday morning, patient was smiling and appeared to be back to his normal self prior to being dropped off at daycare. 4. Thursday evening, around 7 pm, the caretaker called parents and informed them that ?the baby is not well, baby is not breathing well.?  EMS was called and the adult son of the caretaker initiated CPR.  5. As per EMR and review of EMS documentation: ?they arrived at the house to find the baby being held by MPD; he was lethargic, unresponsive, had irregular respirations and was cool to touch. They lad the baby on the couch for assessment; the baby subsequently had ?decorticate posturing? with Left gaze deviation GCS =3. He had a total of 3 of these spells and was given midazolam. En route to the ED the baby had intermittent bradycardia, then tachycardia and irregular respirations. On arrival to ED the baby was being bagged BVM. He subsequently had bradycardia and a rapid response was called; he required full resuscitation. He had intermittent generalized tonic/clonic seizures and was given lorazepam followed by a bolus of levetiracetam 50 mg/kg x1. He then had Right focal seizures and was given bolus of fosphenytoin 20 mg/kg x1. He was able to maintain an airway with adequate saturation and did not require intubation. Initial temperature = 35.6 rectal Routine laboratory diagnostics revealed anemia, thrombocytosis, lactic/respiratory acidosis. Routine neuroimaging [head CT] revealed mixed density bilateral SDH R> L; there was acute bleed in the bilateral cerebral convexities L > R. ? 6. Patient arrived at the hospital unresponsive, receiving assisted breaths via BVM. Patient became bradycardic-chest compressions were started and epi x2 and bicarb given. The patient was not intubated and was put on high flow NC. Patient was taken to the CT scanner where he was noted to have acute intracranial bleeding. 7. MRIs revealed that patient had stable subacute bilateral subdural hematomas as well as a predominantly dorsal subdural hematoma extending from the level of the lower thoracic spine through the sacrum. A smaller ventral bleed was also present in the lumbar spine. Ophthalmology exam revealed bilateral retinal hemorrhages. All tests for underlying blood and clotting disorders were negative.  8. No signs of external trauma were found. No bone fractures were found. No accidents or intentional trauma were noticed by any caregivers of the child.  9. Due to the brain bleeding, spinal bleeding and retinal hemorrhages, physicians determined that patient?s presentation was consistent with abusive head trauma (sometimes referred to as ?Shaken Baby Syndrome?) and law enforcement was called to investigate.