Symptom-Based Diagnosis in Pediatrics (CHOP Morning Report) 1st Ed.

CASE 18-4

Fourteen-Year-Old Boy

SAMIR S. SHAH

HISTORY OF PRESENT ILLNESS

A 14-year-old boy is taken to the emergency department by paramedics after “passing out” at school. The history provided by the paramedics is that he had a nosebleed and stood up. Shortly after standing, he became lightheaded and passed out, falling to the ground. The paramedics found him to be unresponsive. They placed him in a cervical collar, inserted an intravenous line, and administered naloxone and dextrose en route to the emergency department. There was no response from either of the medications.

MEDICAL HISTORY

The boy has been a healthy teenager who only suffers from seasonal allergies. One year prior to this presentation he had testicular torsion and underwent an orchiopexy. Otherwise, he is currently not taking any medications and is also not allergic to any medications. His immunization status is up-to-date. He lives at home with his parents and sister. He is in the eighth grade and is a B/C student. He denies the use of any illicit drugs.

PHYSICAL EXAMINATION

T 37.9°C; HR 110 bpm; RR 16/min; BP 129/72 mmHg

Weight more than 95th percentile and Height 50th percentile

On examination he was somnolent, but arousable to verbal stimuli. Shortly after stimulation, he fell asleep. His head and neck examination revealed 5 mm pupils that were briskly reactive to 2 mm bilaterally. His extraocular muscles were intact. He has dried blood in his right nares and an eschar on the anterior nasal septum. The cervical collar was in place; there was no spinal tenderness elicited. His lungs were clear to auscultation. His cardiac examination had no murmurs or abnormal heart sounds. His pulse was regular and strong. His abdominal, rectal, extremity, and skin examinations were entirely normal. On neurologic examination he was found to be arousable to verbal stimuli. He was oriented to person, time, place, and situation. He followed simple commands and was able to count backwards from 100 by 7. His deep tendon reflexes were 2+ and symmetric. His sensation was intact. However, his motor strength was rated 2/5 in both arms and legs. He was able to move his extremities in the plane of the bed, but could not lift them against gravity.

DIAGNOSTIC STUDIES

A complete blood count and basic metabolic panel returned with normal values. His urine and serum drug screens were negative. A head CT did not reveal intracranial pathology. A chest radiograph was normal. An electrocardiogram revealed a normal sinus rhythm with normal intervals. A lumbar puncture was performed with an opening pressure of 17 cm H2O, 1 WBC/mm3 and 0 RBC/mm3, protein and glucose normal, and Gram stain with no bacteria and no WBCs present.

COURSE OF ILLNESS

The patient underwent the above studies while in the emergency department. He did not regain his strength or return to baseline mental status after several hours and was admitted to the inpatient service.

DISCUSSION CASE 18-4

DIFFERENTIAL DIAGNOSIS

This patient presents with a change in mental status with a history of syncope. The differential diagnosis for the change in mental status can be discussed using the mnemonic AEIOU TIPS: A lcohol; Electrolytes and endocrine; Insulin, intussusception and intoxication; Ox ygen; U remia (and other metabolic causes); T rauma, tumors, and temperature; I nfection; P sychiatric; and S troke (Table 18-4). The clinician should consider vascular events such as cerebral thromboembolism or intracranial bleeding. Intussusception may cause depressed mental status or somnolence infants and toddlers. Trauma, including nonaccidental trauma, should always be considered a possibility with resultant cerebral contusion and concussions. Toxic ingestions may include medications (e.g., sulfonylurea), illicit drugs, and heavy metals. Metabolic disorders such as hypoglycemia and other electrolyte abnormalities can present with decreased mental status. Infectious etiologies such as meningitis and encephalitis should always be considered. Neoplasms in the brain can produce depressed mental status as well as a cancer that produces profound anemia. And finally, seizures are a frequent cause of depressed mental status whether the patient is postictal or in subclinical status epilepticus.

TABLE 18-4. Causes of altered mental status.

Image

DIAGNOSIS

This patient was admitted to the inpatient service. The sudden and prolonged weakness that began after a syncopal episode was difficult to explain. His neurologic examination was normal. On further questioning, it became evident that he was under a significant amount of stress at school. His grades were poor, he had been in several fights recently, and felt that there is a group of kids at school who were “out to get him.” The diagnosis is malingering.

INCIDENCE AND EPIDEMIOLOGY

Malingering is described as the intentional production of or gross exaggeration of physical or psychological symptoms. It is frequently motivated by external incentives such as avoidance of school, work, and military obligations. Malingering differs from factitious disorder in that there is no external incentive in factitious disorders. There is a clearly definable goal for the malingering patient. The actual incidence of malingering is unknown; however, it is a rare phenomenon in children. It is more common in patients who are in a restrictive environment such as incarceration or the armed forces. Malingering represents a conscious attempt to avoid an unpleasant situation. Somato-form disorders, such as conversion disorders, are much more common in children and represent an unconscious attempt to handle unpleasant emotions without an obvious external incentive. Malingering is not considered a mental disorder.

CLINICAL PRESENTATION

Many malingering patients appear aloof and hostile toward the physician in an attempt to delay the discovery of their deception. They will readily submit to painful diagnostic procedures. By contrast, patients who have conversion disorders tend to be very friendly and appropriately concerned about diagnostic procedures.

DIAGNOSTIC APPROACH

Psychologic evaluation. According to the DSM-IV, malingering should be suspected when any of the following are noted, particularly in combination: (1) medicolegal context, that is, the patient was referred to the physician by an attorney; (2) there is an obvious discrepancy between the patient’s claimed stress and disability and the objective findings; (3) there is a lack of cooperation during the examination and with the recommended treatment; and (4) the presence of an antisocial personality disorder.

Other studies. Most patients who present with malingering have vague and subjective complaints such as headache, pain in a body part, dizziness, amnesia, anxiety, or depression. These symptoms are difficult to disprove. Objective tests such as audiometry, EMG, nerve conduction studies, or evoked potential studies may be of benefit for particular symptoms.

TREATMENT

The patient suspected of malingering should be thoroughly evaluated in an objective manner. Merely linking the symptoms to psychosocial stressors may be therapeutic. Unfortunately, in the adult patients, confrontation frequently occurs which results in either the end of the doctor-patient relationship or the patient becomes more on guard and proof of the deception becomes impossible. Careful evaluation of the patient and environment often reveals the cause of the symptoms without the need for a confrontation. Preservation of the doctor-patient relationship is important to arrive at the correct diagnosis and long-term care of the patient. Of note, in malingering, symptom relief is not obtained by suggestion or hypnosis as it is in the somatoform disorders. Psychiatric referral may be warranted.

SUGGESTED READINGS

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC, American Psychiatric Association; 1994:683.

2. Prazar G. Conversion reactions in adolescents. Pediatr Rev. 1987;8:279-286.

3. DeMaso DR, Beasley PJ. The somatoform disorders. In: Klykylo WM, Kay J, Rube D, eds. Clinical Child Psychiatry. Philadelphia, PA: W.B. Saunders Company; 1998;429-437.

4. Nemzer ED. Somatoform disorders. In: Lewis M, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook. 2nd ed. Philadelphia, PA: Williams & Wilkins; 1996:693-702.