|
| Date | Chief complaint/history | Consultant | Diagnostic study | Findings and treatment |
|
9/7/2014
Urgent care visit | (i) Vomiting
(ii) Unintentional weight loss | Primary care | | Prescribing ondansetron and follow-up with PCP for weight loss |
|
9/9/2014
PCP follow-up office visit | (i) Gastritis
(ii) Weight loss
(iii) Orthostatic hypotension
(iv) Intermittent right lower back pain with radiation into the right leg | Primary care | (i) Beck’s Anxiety and Depression Inventory
(ii) CBC, CMP
(iii) Lipid Panel
(iv) TSH | (i) Mild anxiety
(ii) No depression
(iii) All labs normal
(iv) Normal reflexes, muscle tone, coordination |
|
9/11/2014
ER visit | (i) Vomiting
(ii) Dehydration
(iii) Weight loss | | (i) Chest X-ray
(ii) CBC, CMP
(iii) Urine pregnancy test and UA
(iv) ESR
(v) CRP | (i) All normal, except low prealbumin at 18 and sodium 136
(ii) Given IV fluids
(iii) Discharged on promethazine for vomiting and nausea |
|
9/14–9/22/2014
Community hospital admittance with same day transfer to children’s hospital | (i) Intractable vomiting
(ii) Weight loss
(iii) Hypertension
(iv) 5-day history of hiccoughs | Pediatric GI | Right upper quadrant ultrasound | Small amount of gall bladder sludge, no gallstones |
| CT abdomen pelvis with contrast | Normal |
| EGD | (i) H. Pylori gastritis, biopsy diagnosis
(ii) Triple therapy was initiated, changed to IV due to persistent nausea and vomiting, completed |
| Colonoscopy with biopsies | No abnormalities |
| Pediatric nephrology | Urine VMA, Renal ultrasound | Both normal |
| Pediatric nutrition | | (i) 15% weight loss in 3 months
(ii) 27th percentile weight for age
(iii) 32nd percentile stature for age |
| Neurology | | Normal strength, tone, movement |
Discharge Diagnosis:
H. pylori gastritis
medication:
Triple therapy for H. pylori: clonidine patch, pantoprazole, sucralfate |
|
9/28–10/4/2014
ER visit/transfer to children’s hospital | (i) Pancreatitis
(ii) Hypertension
History: 2 fleeting episodes of blurry vision, lightheadedness, pain, itching on left side of face since 9/24, syncope on 9/25 with 10-second loss of consciousness, difficulty following commands | Pediatric neurology | (i) Brain CT
(ii) Brain MRI | (i) Both Normal
(ii) Normal strength, tone, movement
(iii) PT consult for instability in ambulation |
| Pediatric GI | EGD with biopsy for emesis | (i) Gastric nodularity, H. pylori positive
(ii) Lipase 465–1498, Lactic acid 2.7 elevated |
| Pediatric nephrology | Echo | Normal |
Discharge diagnosis:
Dehydration, abdominal pain, intractable vomiting, syncope, H. pylori infection, neuropathic left facial pain (worsened on gabapentin, so stopped)
Medication:
Clonidine patch 0.1 mg/24 hr weekly, pantoprazole 40 mg 2x daily, sucralfate 1 g 2x daily prn, ondansetron 8 mg 2x daily prn |
|
10/6/2014
PCP follow-up from hospitalization | (i) Pancreatitis
(ii) Hypertension
History: lower extremity weakness, numbness in fingers, hyperesthesia of the face and head, shaking episodes, feeling cold, mom reports symptoms worsening, had “seizure” in hospital | | (i) Lipase
(ii) West Nile IGG and IGM
(iii) ESR
(iv) TSH | (i) Physical exam: normal reflexes, no cranial nerve deficits, normal muscle tone, decreased sensation in extremities
(ii) Labs normal except elevated lipase (277)
(iii) Cold intolerance
(iv) Spells
(v) Urgent referral to neurology |
|
10/7–9/2014
Office visit with pediatric neurology resulting in hospitalization at children’s hospital | History: shaking episodes since 9/27 affecting head and upper extremities, occur randomly, last seconds with no postictal confusion, pins and needles sensation affecting entire face and left arm, itching and burning of left face with hyperpigmentation, weakness requiring wheelchair | Pediatric neurology, pediatric GI, adolescent medicine, neurosurgery | Neurological exam | (i) Cranial nerves intact
(ii) Sensation intact
(iii) Bilateral upper and lower extremities
(iv) Right upper extremity strength 5/5
(v) Left upper extremity strength 4/5
(vi) Pronator drift
(vii) Bilateral lower extremities 4/5
(viii) Gait weak on left side |
| Continuous 24-hr. Video EEG | Normal in awake, drowsy, sleeping states; 7 episodes with no EEG correlate |
| EMG and Nerve conduction study | Normal |
(i) Ceruloplasmin
(ii) Vitamin D
(iii) Cortisol
(iv) Lipase
(v) ANA profile
(vi) Entrovirus | (i) Low
(ii) Low
(iii) Normal
(iv) Elevated lipase (771)
(v) Negative
(vi) Negative |
Discharge Diagnosis:
(i) Left-sided upper and lower extremity weakness
(ii) Spells
Medications:
Vitamin D deficiency, hydrocortisone cream, ondansetron, sucralfate, vitamin D, multivitamin, ranitidine |
|
10/18/2014
PCP f/u hospitalization | (i) Pain in bilateral upper extremities, chest, low back
(ii) Shaking | | Lipase | (i) Almost normal (126)
(ii) Myalgias
(iii) Parasthesias
(iv) Spells
(v) Tremors
(vi) Hypertension
(vii) Urgent referral to pediatric neurology |
|
10/23/2014
Pediatric neurology | (i) Pain in bilateral upper extremities, chest, low back
(ii) Shaking | Pediatric neurology | (i) MRI whole spine, with and without contrast (performed on 11/3)
(ii) Neurological exam | (i) Tremors
(ii) Parasthesias (face, arms, trunk, legs)
(iii) Nonspecific muscle tenderness, possible weakness
(iv) Reflexes normal, downgoing plantar Muscle normal bulk, tone, strength
(v) Decreased cold face to T4, decreased pinprick face to toes.
(vi) Recent history of pancreatitis |
|
10/29/2014
pediatric GI f/u hospitalization | Intractable vomiting | Pediatric GI | Serum copper | Normal |
|
11/4/2014
PCP follow-up | MRI results | | (i) MRI cervical spine
(ii) MRI thoracic spine, lumbar spine, sacrum, coccyx | (i) 4 × 3 cystic dilation of the central canal from C5 to T2
(ii) Increased signal in the medulla oblongata and C2 to C5, relative expansion of the cervical spinal cord
(iii) Syringomyelia
(iv) Normal |
|
11/7/2014
pediatric neurosurgery | Abnormal cervical spine MRI
History: decreased activity due to neck pain, difficulty starting urination, hand tremor, weakness in all extremities, numbness and tingling in left leg | Pediatric neurosurgery | Neurological exam | (i) Abnormal reflexes, increased muscle tone, clonus in both feet, spastic gait
(ii) No muscle atrophy, no cranial nerve or sensory deficit, normal position and vibration sense, normal coordination
(iii) Possible multilevel spinal cord tumor
(iv) Referred to 2nd children’s hospital neurosurgery |
|
11/16–25/2014
ER visit and hospitalization at a second children’s hospital | Possible multilevel spinal cord tumor | Child neurology | (i) Lumbar puncture
(ii) MRI cerv. spine | (i) CSF positive for neuromyelitis optica (NMO), WBC 18, RBC 3, gram stain culture negative, IgG index 0.6, oligoclonal bands negative, ACE 1.1, NMDA receptor antibody negative; seropositive for NMO.
(ii) Extensive cervical spine longitudinal myelitis; confluent ill-defined, partly enhancing, abnormal intramedullary signal from pontomedullary junction through the lower cervical cord. No optic nerve abnormality.
(iii) Dystonia
(iv) Tegretol 300 mg 3x daily
(v) 2 days of IV IG
(vi) 5-day course of IV methylprednisone, discharged on prednisone taper |
Discharge diagnosis:
(i) Neuromyelitis optica (NMO)
(ii) Cervical myelopathy
(iii) Dystonia |
|
12/3/2014
Follow-up with pediatric neurology | | | | (i) Neuromyelitis optica (NMO)
(ii) Cervical myelopathy
(iii) Secondary Paroxysmal Kinesigenic Dyskinesia (PKD)
(iv) Start Cellcept with slow increase to goal of 1000 mg BID |
|
1/22/2015
Follow-up with PCP | (i) Neuromyelitis optica
(ii) Cervical myelopathy | | | (i) Weight gain since November of 34 lb
(ii) Taking mycophenolate, carbamazepine, prednisone
(iii) Referral to ophthalmology for baseline evaluation and ongoing care |
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