Age: 1.25
Sex: M
Vaccine: DTAP
Symptoms: Laboratory test normal, Muscle tightness, Nuclear magnetic resonance imaging normal, Posture abnormal
Clinical narrative: From ED H and P: HPI Comments: 15 mos old previously healthy male who presents to the ED after a phone discussion with their PCP.  Mother, who is a PA informs us that the patient has been having episodes today, the longest of which was 45 minutes wherein he would have markedly diminished head control ability.  The patient would often sluggishly let his chin rest on his torso, and occasionally would let his head flip backwards and flop around.  During this time he would be slightly irritable.  Mom feels the R sided cervical posterior muscles have been slightly firm. Patient throughout the day has noted to be slightly more clingy. For about 10-15 minutes today the patient stopped speaking which is highly unusual for the patient.  He has had marked difficulty ambulating - normally he can run in a straight line but now walks very unsteady.  Healthy full term child otherwise. Sx started about 11 am-- improved over 12 hours. Resolved completely after about 24 hours. Past Medical History Past Surgical History Family History Review of Systems Constitutional: Negative for fever, chills, activity change, crying, irritability and fatigue. HENT: Negative for hearing loss, neck pain and neck stiffness.  Eyes: Negative for pain, discharge, redness and itching. Respiratory: Negative for cough, shortness of breath, wheezing and stridor.  Cardiovascular: Negative for chest pain, leg swelling and cyanosis. Gastrointestinal: Negative for nausea, vomiting and abdominal pain. Genitourinary: Negative for dysuria, urgency, decreased urine volume and difficulty urinating. Musculoskeletal: Positive for gait problem. Negative for joint swelling. Skin: Negative for color change, pallor and rash. Neurological: Positive for speech difficulty. Negative for seizures, weakness and headaches. Psychiatric/Behavioral: Negative for behavioral problems and agitation. Physical Exam Nursing note and vitals reviewed. Constitutional: He appears well-developed and well-nourished. He is active. No distress. HENT:  Head: Atraumatic. No signs of injury.  Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal.  Nose: Nose normal. No nasal discharge. Mouth/Throat: Mucous membranes are moist. Dentition is normal. No dental caries. No tonsillar exudate. Oropharynx is clear. Pharynx is normal. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. Neck: No rigidity or adenopathy. When patient has his head slumped to the chest his R sided cervical paraspinal muscles feel more tight and protuberant. Cardiovascular: Regular rhythm, S1 normal and S2 normal.  Pulmonary/Chest: Effort normal. No nasal flaring or stridor. No respiratory distress. He has no wheezes. He has no rhonchi. He has no rales. He exhibits no retraction. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness. There is no rebound and no guarding. Musculoskeletal: Normal range of motion. He exhibits no edema, no tenderness, no deformity and no signs of injury. Neurological: He is alert. He displays no atrophy. No cranial nerve deficit. He exhibits normal muscle tone. Coordination and gait abnormal.  Reflex Scores:  Patellar reflexes are 2+ on the right side and 2+ on the left side. Does not make coherent speech or verbal efforts during exam.  Will occasionally stop holding head up and keep it resting on his torso.  Gait markedly ataxic and abnormal.  Skin: Skin is warm and dry. Capillary refill takes less than 3 seconds. No petechiae, no purpura and no rash noted. He is not diaphoretic. No cyanosis. No jaundice or pallor. MEDICAL DECISION MAKING/PLANS: 15 mos old male with abrupt onset of ataxia, poor head control, loss of speech.  Findings concerning for pathology including but not limited to posterior fossa tumor, demyelinating syndrome, less likely hydrocephalus, viral process. Patient is afebrile and aside from neurological findings, otherwise well appearing, do not suspect infectious etiology. Have discussed on phone with peds neurology who agrees with plan for STAT head CT and basic lab work.  Will likely plan for admission and formal neurologic consult with additional neuroimaging if head CT not indicating acute surgical emergency.  Patient NPO for now.  Reviewed: past records, current meds, allergies, VS and nurses notes. Ordered tests: CT Scan and labs.