Interesting Medical Case

[han14tra]

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I am an EMT, and we had a call for a middle aged male with acute onset amnesia that started 1 hour prior to our arrival. He was relaxing when it started because he had a headache. HA was on the top of his head. Pain scale 9/10. Blood glucose level: 140. Pulse, BP, and O2 saturation were all normal.

He believed that he was a 13 year old who was playing football with his friends and got hit in the head. Interestingly, he actually did sustain a concussion when he was 13 years old when he was playing football. He didn't recognize his wife or kids. When I asked for his address, he told me the address of where he lived when he was 13.

Social Hx: No hx of illegal drug use. However, he did have a duragesic patch that was d/c 1 week ago. EtOH was used last night (1 drink). He is a smoker. Normal weight.

PMH: HTN, back pain.
Meds: HCTZ, trazadone, fexofenadine.

Ideas? What could this be? What tests would you do?

I'm only pre-med, but I like to think about this stuff. I'd probably do a CT of the head. Suspect a possible hemorrhage since he has a hx of HTN. He had normal strength in his extremities, no facial droop, spoke normally. Which area of the brain do you think is involved?

 

[Vonsmack]

Probably Munchausens, send him home..

 

[Dral]

Not a bad place to start, but HTN often causes lacunar infarcts in the Thalamus/Pons/BG. It's certainly not out of the realm of possibilities though. You'd probably want to follow up with MRI as well to really pinpoint the lesion if you saw one on CT.

Since it's affecting his memory, my first inclination would be to guess that he suffered from a lesion of the hippocampus (medial temporal lobe)...so possibly a problem with the posterior cerebral artery?

If it was a spontaneous bleed (subarachnoid bleed for instance), by the way I understand it at least, the patient would rate the pain as 90/10 opposed to 9/10.

 

[FutureDoc4]

Doesn't recognize faces (wife and kid--prosopagnosia), with memory involvement likely involves the fusiform gyrus and medial temporal lobe agreed on PCA hemorrhage.

 

[WellWornLad]

Doesn't recognize faces (wife and kid--prosopagnosia), with memory involvement likely involves the fusiform gyrus and medial temporal lobe agreed on PCA hemorrhage.

Prosopagnosiacs wouldn't deny having a wife and kid, and they certainly wouldn't think they were 13.

This seems like a problem with retrieval, not consolidation, so I wouldn't expect specific hippocampal involvement. Dissociative amnesia/fugue is my guess.

 

[starfishprime]

He believed that he was a 13 year old who was playing football with his friends and got hit in the head. Interestingly, he actually did sustain a concussion when he was 13 years old when he was playing football. He didn't recognize his wife or kids. When I asked for his address, he told me the address of where he lived when he was 13.

...and so Dr. Beckett finds himself leaping from life to life, striving to put right what once went wrong, and hoping each time that his next leap, will be the leap home.


👍👍👍

 

[loveoforganic]

I wouldn't necessarily jump straight to Munchausens... but this definitely sounds like a psych eval coming up. In the mean time, electrolytes? My dad overhydrated a while ago and had some (otherwise) inexplicable dissociative symptoms. Competely resolved on saline IV.

 

[han14tra]

I wouldn't necessarily jump straight to Munchausens... but this definitely sounds like a psych eval coming up. In the mean time, electrolytes? My dad overhydrated a while ago and had some (otherwise) inexplicable dissociative symptoms. Competely resolved on saline IV.

We gave a saline IV on the ambulance with a 45 minute transport. His condition kept worsening. His HA got worse and he became less verbal. Hydration issues were what the paramedic thought of at first.

 

[neurolddoc]

I would characterize his presentation more as a confusional state rather than an amnesic one. He onset of the headache would be very important to clarify, as an abrupt onset would imply a bleed whereas a slower onset would be less specific but could be consistent with a meningo-encephalitis. HSE would be of particular concern as this has a predilection for the temporal lobes. Precise localization is really not possible given the history and exam available. I would also be suspicious about a toxic encephalopathy and would want to clarify the narcotic/other substance use history.

On presentation to the ER he should have a CT of the brain to rule out bleed as well as CBC, metabolic studies, and a tox screen. If the CT is negative for bleed, he needs an LP followed by MRI and EEG.

 

[paco4488]

It could be transient global amnesia. It can be brought on by pain and may be associated with migraines. If not, still something cool to read about.

http://emedicine.medscape.com/article/1160964-overview

 

[FutureDoc4]

..

 

[arif]

Prosopagnosiacs wouldn't deny having a wife and kid, and they certainly wouldn't think they were 13.

This seems like a problem with retrieval, not consolidation, so I wouldn't expect specific hippocampal involvement. Dissociative amnesia/fugue is my guess.

Agree,i'll go wiz dissociative amnesia