A 9-Year-Old Girl With Declining School Performance

Faisal M. Mawri, MD; Peter Stoyanoff, MD; Meaghan Misiasz, BA; Jillian Ewing, BS; David Ishiyama


May 14, 2015

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.


A 9-year-old girl with no significant medical history presents to the pediatric emergency department with a chief symptom of several episodes of vomiting. The vomiting started early in the morning on the day of presentation. The emesis has been nonbloody, nonbilious, and nonprojectile. A total of five episodes have occurred in the 6 hours before presentation.

Upon further questioning, the patient states that she has been frequently experiencing bilateral throbbing headaches over the past 2 weeks, which she describes as being worse in the morning and associated with nausea. The duration of the headaches ranges from 2-4 hours, with a recent increase in duration and severity. Coughing, sneezing, or changing the position of the head has had no effect on the headache intensity.

The patient denies having any recent trauma, fever, neck pain, cough, nasal discharge, chest pain, shortness of breath, or abdominal pain. She has also been noted to have a change in her gait, with unsteadiness and occasional falls (particularly at night). The remainder of her review of systems is negative.

The patient's school performance has reportedly deteriorated over the past year, with no clear explanation. She is not currently taking any medications and has no history of allergies. The patient's family history is significant only for diabetes mellitus and hypertension in her maternal grandfather.


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