Rachael Batabyal, MD, Children’s National Medical Center

Case: 8 yo male presenting with auditory hallucinations with normal labs notable for a urinalysis with sterile pyuria. Head imaging was unremarkable.

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Discussion:

The discussion for this case focused on 2 features:

1. Positive UA without urinary symptoms: While this is part of our standard lab work up for psychiatric complaints, treating in the absence of symptoms is not indicated. Instead, sending a culture with anticipatory guidance to watch for symptoms is warranted. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234948/
2. Differential and disposition for auditory hallucinations: While the initial work up was reassuring against many of the more common causes, there is a broad differential. This makes disposition challenging. In an otherwise well patient, it can be hard to justify extensive work up. Depending on family’s comfort, some of these can be followed and worked up as outpatient

The discussion for this case ultimately revealed the major dilemma of this case was disposition of this patient. Dr. Pershad reaffirmed the notion that if something is off in your gut, trust it! He reminded us to empower ourselves that as the primary ED provider for this child, we may choose to involve consultants, but may not always listen to their advice. No matter the level of training (trainee or attending) we should have to hesitation with escalating to the consulting attending for clarity (even at 2 am!). Not only does this allow us closure, learning pearls, and a shared mental model. It allows us the ability to emphasize the pertinent red flags worrying us that may not have been translated through the beloved childhood game of telephone that plagues teaching hospitals.

Denouement

The psychiatry attending was contacted directly to voice concerns regarding patient’s mental status who ultimately felt that the patient could be boarded in the ED overnight to be evaluated in the morning by the psychiatry attending. After evaluation it was felt that these were more consistent with anxiety and possible depressive disorder than from a primary psychotic disorder as more mental health history was provided than initially revealed. He was scheduled for a follow up visit with his outpatient psychiatrist.

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