34 year old girl with mild mental retardation, asthma and "mood control issues" presented to our hospital because of episodes of confusion. She would be sitting and just relaxing and, all of a sudden she would start staring at the ceiling with her lips quivering and stop talking. This would last for a few minutes and then she would be back at her baseline.
Aides from her group home kept saying... We think she's pretending to get attention.
Of course, she can't give any history. She doesn't remember these episodes. The work up in the ED is completely negative. They ask me to admit because "her psych meds probably just need adjusting but we should monitor her to figure out what is going on." Psychiatrist had seen her in the ED and felt that "maybe she's angry about something and expressing it this way."
She gets admitted overnight by my colleague and really nothing happens on her shift. Colleagues sign out to me: she seems fine...I don't why the ED MD wanted me to admit!
I go meet the patient... She's a sweet girl. Mind of a five year old. The aide from group home, who has to sit with her alone in the hospital, says: "can I just take her home... She seems fine!" I politely offer "give me 24 hours and if she remains stable we will send her back." I tell the nurse to call me when or if an "altered mental status" episode happens.
2 hours later:
CODE Rapid response to pts room number
Me: running in What's going on?
Nurse: She's just sitting there starting at the ceiling
Aide: It's probably crap .. This is what she always does
Me: Screaming at the girl Sweetheart I am gonna have to stick a tube down your throat if you are really having a seizure!
(This was a bullshit threat but anyone lying usually "wakes up" at that point...this patient however, has no change.)
Me: give her a bit if painful stimuli...no change Ok fine send a stat prolactin and let's give her two of Ativan
Nurse does this and the patient calms down. Falls back in bed and goes to sleep. A few minutes later she wakes up and doesn't remember anything that happened.
While I am waiting for the blood test....I get a page from the psych nursing supervisor. "Oh we know about her... She's always here making things up."
As I am talking to her...I get a text from the patient's nurse on my phone... The prolactin is high!
We go back and add on prolactin to her blood tests when she came in (luckily there was enough blood left over from the day before)... This was a few hours after her episode at the group home... That level is low!
She was having absence seizures!
It's a rare diagnosis in kids...Rarer still in adults!
Sometimes you just have to stick to your guns!
Till next time!