Age: 13.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Head banging, Intentional self-injury, Quarantine, SARS-CoV-2 test positive, Sneezing
Clinical narrative: 13y.o. male with PMH of cerebral palsy, ARID1B-related (Coffin-Siris) syndrome-spectrum neurodevelopmental disorder, developmental delay, agitation/self-injurious behavior requiring protective helmet, encopresis with constipation and overflow incontinence of stool, aerophagia, and hx of GI perforation in 2020 who presented with worsening agitation, self-injurious behavior and mother's concern that this was secondary to abdominal pain. Patient was going to go to camp today, but mother was too concerned about his behavior and so brought him to the ED. Mother says that patient has worsening agitation and self-injurious behavior (crying excessively, banging head on items, hitting mother, etc.) in the past that has been a sign of abdominal pain. She say that these behaviors have increased recently. Per mother, patient is nonverbal and has not been able to demonstrate abdominal tenderness in the past. Mother says that his last BM was early yesterday (08/07/2022). She says that he typically has a lot of flatulence, but has not had much recently. She states that his appetite has been decreased for the last 6 weeks. Patient has a long history of encopresis with constipation and overflow incontinence of stool. He typically will use a diaper, however can sometimes sit on the toilet with assistance by his caretaker. Mother says that a few months ago, although previously he would produce occasional hard pebble balls, he was now  experiencing explosive diarrhea. Mother says that she cut down his bowel regimen, stopping Colace, and decreasing Dulcolax to 15 from 30, while continuing Miralax. Diarrhea is brown/yellow in color. Patient was last seen by GI on 04/15/2022. There they recommended use of milk of mag, periactin, Levsin, speaking with a GI dietitian and trial of pecid. Currently patient is not taking of any of those medications. An abdomen XR on that same date, did show moderate gaseous distention. Their next appointment with GI is in 2 weeks. Patient has had previous GI scopes. Patient had an EGD and colonoscopy in Feb 2021 that only showed duodenitis.  Of note, family had COVID start of July, ended quarantine more than 2 weeks ago. Family tested positive, patient was assumed positive (not tested due to agitation), had sneezing/coughing. Family did have diarrhea as one of their symptoms. Patient's diarrhea does predate family's symptoms. Patient has a long psychiatry related history. Patient has had multiple psych admissions at facility. Patient has been previously taken olanzapine, valproic acid, clonidine and risperidone. Per mother, they follow with Dr. who 1 month ago began a med washout as none of the medications have been helping. Mother says that currently, she administers medical grade THC solution that she gets from a dispensary that is mixed in juice and given twice a day.  Further chart review shows that patient was seen in 03/10/2021 for a similar presentation of worsening behavior. At the time, patient received an extensive work-up that included a dental examination, rheumatology and neurology consultation for autoimmune encephalitis and psychiatry consult who had started the patient on some of his previous anti-psychiatry medications. Per the note, it appears that the diagnosis most favored was that this behavior was most consistent with early pubertal changes. Patient is a 13y.o. male with PMH of cerebral palsy, ARID1B-related (Coffin-Siris) syndrome-spectrum neurodevelopmental disorder, developmental delay, agitation/self-injurious behavior requiring protective helmet, encopresis with constipation and overflow incontinence of stool, aerophagia, and hx of GI perforation in 2020 who presented with worsening agitation, self-injurious behavior and mother's concern that this was secondary to abdominal pain. Patient was going to go to camp today, but mother was too concerned about his behavior and so brought him to the ED. Mother says that patient has worsening agitation and self-injurious behavior (crying excessively, banging head on items, hitting mother, etcc..) in the past that has been a sign of abdominal pain. She say that these behaviors have increased recently. Per mother, patient is nonverbal and has not been able to demonstrate abdominal tenderness in the past.  Mother says that his last BM was early yesterday (08/07/2022). She says that he typically has a lot of flatulence, but has not had much recently. She states that his appetite has been decreased for the last 6 weeks. Patient has a long history of encopresis with constipation and overflow incontinence of stool. He typically will use a diaper, however can sometimes sit on the toilet with assistance by his caretaker. Mother says that a few months ago, although previously he would produce occassional hard pebble balls, he was now  experiencing explosive diarrhea. Mother says that she cut down his bowel regimen, stopping colace, and decreasing dulcolax to 15 from 30, while continuing Miralax. Diarrhea is brown/yellow in color.  Patient was last seen by GI on 04/15/2022. There they recommended use of milk of mag, periactin, Levsin, speaking with a GI dietitian and trial of pecid. Currently patient is not taking of any of those medications. An abdomen XR on that same date, did show moderate gaseous distention. Their next appointment with GI is in 2 weeks. Patient has had previous GI scopes. Patient had an EGD and colonoscopy in Feb 2021 that only showed duodenitis.  Of note, family had COVID start of July, ended quarantine more than 2 weeks ago. Family tested positive, patient was assumed positive (not tested due to agitation), had sneezing/coughing. Family did have diarrhea as one of their symptoms. Patient's diarrhea does predate family's symptoms. Patient has a long psychiatry related history. Patient has had multiple psych admissions. Patient has been previously taken olanzapine, valproic acid, clonidine and risperidone. Per mother, they follow with Dr. who 1 month ago began a med washout as none of the medications have been helping. Mother says that currently, she administers medical grade THC solution that she gets from a dispensary that is mixed in juice and given twice a day.  Further chart review shows that patient was seen in 03/10/2021 for a similar presentation of worsening behavior. At the time, patient received an extensive work-up that included a dental examination, rheumatology and neurology consultation for autoimmune encephalitis and psychiatry consult who had started the patient on some of his previous anti-psychiatry medications. Per the note, it appears that the diagnosis most favored was that this behavior was most consistent with behavioral changes due to early pubertal changes. During his hospital admission, Pt was started on Zyprexa and we noticed a decrease it the number of aggressive outburst. He was also evaluated by GI and had upper endoscopy that showed mild duodenitis therefore patient was started on Lansoprazole. Patient also had stool culture which returned negative. He was also started on Levsin and home bowel regimen was restarted. Patient was also evaluated by surgery who recommended a CT abdomen with PO and IV contrast. After discussion with anaesthesilogy and GI team and due to patient needed to be intubated for imaging decision was made to hold of on any additional imaging.  Patient follows with GI clinic and as an appointment scheduled for next Friday. Since we do not have a GI motility clinic, it was advised that mother establish care there. Mother in agreement with plan.