Approach to altered mental status (pediatrics) Quiz: Ace Your Exams
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A 2-year-old boy is brought to the emergency department for evaluation of altered mental status. Caregivers report that the child underwent a tonsillectomy and adenoidectomy yesterday. Postoperatively, there has been vomiting and minimal oral intake. There have been four minimally wet diapers and no stools in the past 24 hours. The child has a history of gross developmental delay, hypotonia, and poor weight gain. Height is at the 9th percentile and weight is at the 3rd percentile. Blood pressure is 88/42 mmHg, pulse is 140/min, respiratory rate is 38/min, and oxygen saturation is 99% on room air. On examination, the child appears lethargic and is moaning while lying in a caregiver’s arms. Mucous membranes are dry, and capillary refill is 3 seconds. The posterior pharynx shows recent cauterization without active bleeding. No cardiac murmur is appreciated. The abdomen is soft and mildly tender to palpation, without rebound or guarding. Bowel sounds are diminished. Glasgow coma scale (GCS) score is 12. The child opens his eyes to verbal stimuli and withdraws to touch. Laboratory evaluation reveals an ammonia level of 100 µg/dL. Which of the following is most likely to be found on further questioning?
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