Case Index

PATIENT CASE STUDIES
Case 32. (Pediatric Neurology Case 2.)


Case discussion

History: A seven month old boy is brought to the emergency room by her mother's boyfriend who has been baby sitting. He went to check on the baby while the infant was taking a nap. He found the baby "barely breathing and lifeless" in the crib.

Exam: The infant has shallow respirations and when stimulated he has a high pitched cry. A few bruises are noted on the extremities and retinal hemorrhages are present. The head circumference is 48 cm (> 98th %tile). The baby has infrequent spontaneous movements of the extremities, marked hypotonia of the neck, trunk and extremities, and normal reflexes.

  1. Summarize the Case in 1-2 sentences.

    2. A 7 month old boy presents in emergency room with shallow breathing and a large head circumference with retinal hemorrhages, hypotonia of the neck, trunk, and extremities, and bruises on the extremities. Deep tendon reflexes normal.

    good

  2. Discuss lesion localization on the basis of the physical examination.

    3. Problem list:
    Head circumference 48 cm increased intracranial pressure
    Retinal hemorrhageshemorrhages of intraocular vessels
    Shallow respirationsbrainstem
    Hypotonic neck, trunk, extremitiesIn this case this is an UMN lesion because there is no weakness/paralysis spontaneous movements) and there are normal reflexes.
    High pitch crynon-specific sign of encephalopathy
    Bruises on extremitiespossibly due to trauma or vascular

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  3. Discuss underlying pathogenesis on the basis of clinical course.

    4. Because this case is so acute, the cause is likely trauma. Other possibilities include seizure, coma, vascular phenomenon, or infection.

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  4. Indicate one likely clinical diagnosis. List (or classify) alternative diagnoses.

    5. Subdural hematoma and intraocular hemorrhage due to shaken baby syndrome.

    Differential diagnosis: Trauma could also be caused by falling. Intracranial hemorrhage, coup-contracoup trauma, acute encephalopathy, seizure, ischemic attack, meningitis, septisemia, obstructive hydrocephalus, toxins.

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  5. Indicate 2 ancillary tests that would assist in confirming or refuting the clinical diagnosis. Indicate the test results that would confirm the clinical diagnosis.

    6. CT scan, drain subdural hemorrhage.

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  6. Indicate complications of the disease and ancillary tests that would help evaluate them.

    7. Herniation brain stem, coma, respiratory arrest, death.

    good, also intracerebral, subdural, epidural hematoma, retinal hemorrhages, axonal shear injuries, multiple injuries

  7. Discuss how the underlying pathophysiology is relevant in the management of this patient.

    8. Subdural hemorrhage or hematoma can cause increased intracranial pressure and herniation of the brainstem effecting respiration, and pyramidal motor hypotonia. Treatment includes 1st Airway, Breathing, Circulation, then IV, o2 and Monitor, then blood sugar and electrolytes (as stated in lecture). Further treatment would include draining the subdural hemorrhage, giving diuretics and manitol. Removing this child from the home (as well as siblings) is also an important part of this child's treatment.

    good, also cytotoxic edema causing raised ICP is common in patients with closed head injury; the process is similar to that of ischemic stroke