A 15-year-old male came to clinic with a rash on his right arm that had been there for 2-3 days and was pruritic. He had helped a friend do some lawn care 3 days ago. There were no use of new soaps, lotions, detergents, etc. The past medical history revealed an ankle sprain 2 years previously due to sports. The pertinent physical exam showed a healthy male with an area on the inner right forearm ~7 centimeters around with raised red papules that generally were diffuse but some were linear. There were excoriations. The diagnosis of contact dermatitis (possibly poison ivy) was made. The patient was instructed to try some hydrocortisone 0.5% cream and an antihistamine for relief.
As the physician was closing the visit, the mother said, “He’s been having a lot of problems remembering things lately.” His mother said that he had been having problems remembering where clothing items were, when he was supposed to meet the family, and to turn in homework. This was unusual for him and she said that it had been happening for the past 3 weeks since the beginning of school. With further questioning, he had begun the football season, was playing in a special band group, and was taking a full-course of studies at school along with beginning 1 advanced placement class. He did agree that this was happening, and said it was a little difficult to manage the classwork and extracurricular activities. He was staying up much later than he had ever before to finish his homework. He denied any head trauma since football had started or before. His mother agreed that he was staying up much later and that his homework was done well, but just not being turned in.
When he was separately interviewed, he denied substance abuse, depression, mood problems and other stresses. He felt good about himself, his school, athletics, family and friends. He again denied any head trauma. His neurological examination was negative. The physician felt this was normal memory or attentional problems due to stress and sleep deprivation. He recommended more consistent sleep hygiene with catch-up naps on the weekends. The patient was going to use a homework folder along with some written reminders for school. He also agreed to immediately tell his coach and/or parent if he had any head trauma or possible head trauma with football. The family agreed to monitor him and if his symptoms worsened, changed, or new symptoms occurred then they would call for another clinic appointment.
Memory is the ability to recall prior experiences including visual, auditory and spatial relationships. Memory integrates experiences, thoughts and impressions together.
It is an important component of executive functioning and social interaction.
- Working memory – which lasts seconds, usually associated with rehearsal and use of information and is associated with prefrontal cortex and angular gyrus
- Episodic memory – which lasts minutes to years and is associated with the hippocampus and limbus
- Semantic memory – associated with factual information and is associated with the inferolateral temporal lobes
- Procedural memory – associated with performing a common task (e.g. brushing teeth, tying shoes, driving a car, etc.) and is associated with the basal ganglia, cerebellum and supplementary motor area
Memory loss timing:
- Hyperacute – minutes to hours, causes can include migraine, seizures, stroke
- Subacute – days to months, causes can include infectious and inflammatory problems, brain tumors, psychiatric and endocrinological problems
- Chronic – > 2 years, usually due to neurodegenerative process
Memory loss in adults occurs normally with aging and is associated with retrieval problems from the frontal cortex. Normal adult memory loss does not affect activities of daily living and is concerning if it does. For children, many memory problems are because of normal development (i.e. too young to remember where an item was left) or are temporary and/or situational (i.e. adolescent in chaotic household and can’t remember where car keys were left or where supposed to meet friends, etc).
Memory problems that affect function, activities of daily living, appear progressive, appear to involve other cognitive functioning, or that are concerning to the patient, family or friends should be evaluated. Memory problems sometimes are difficult to separate out from attentional problems (e.g. attention deficit disorder, depression) or early mental status changes (e.g. absence seizure, drug abuse). Neuropsychiatric testing may be necessary to help sort out memory and other cognitive deficits.
Physical examination should include, attention to the eyes for ophthalmoplegia or papilledema (increased intracranial pressure), and a neuroexamination including looking for myoclonus, focal motor or sensory problem (tumor, stroke). Skin, hair or weight problems may indicate hypothyroidism. Mental status examination may also help with screening for psychiatry or social problems.
The differential diagnosis of memory problems includes:
- Normal development
- Normal progression of underlying condition – patient with Down Syndrome developing Alzheimer’s-type memory problems
- Unrecognized underlying cognitive, attentional or executive function problems – attention deficit disorder, learning disability, cognitive deficits
- Early onset or subacute underlying medical condition – renal insufficiency, hepatic insufficiency, autoimmune problem
- General life or situational stress
- Sleep deprivation
- Substance abuse – alcohol, marijuana, etc.
- Post-radiation or chemotherapy
- Vitamin B-12 deficiency
- Epstein barr virus
- Systemic lupus erythematosus
- Viral meningitis
- Neurological tumor
- Eating disorder
- Post-traumatic stress disorder
- Head trauma – recognized or unrecognized
- Migraine headache
- Stroke – hemorrhagic, ischemic
- Iron-deficiency anemia
Questions for Further Discussion
1. What are indications for drug testing in adolescents and how should adolescent confidentiality be handled?
2. What cognitive effects can unrecognized head trauma present with?
3. When would neuroimaging be indicated for memory or cognitive problems?
- Symptom/Presentation: Behavior Problems
- Specialty: Adolescent Medicine | General Pediatrics| Neurology / Neurosurgery | Psychiatry and Psychology
- Age: Teenager
To Learn More
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Fenichel GM. Clinical Pediatric Neurology. 4th Edit. W.B. Saunders Co. Philadelphia, PA. 2001;47-52.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2204.
Rosenbloom MH. Chao SZ. Thai JN, Geschwind MD. Evaluation of Memory Deficit. Epocrates Online. Available from the Internet at https://online.epocrates.com/u/2911710/Evaluation+of+memory+deficit/Differential/Overview (rev.12/14/2010, cited 9/19/2011).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital