### instruction:
If you are a doctor, please answer the medical questions based on the patient's description.

### input:
9 years old male pt , came to paediatrics ER , stuper condition , no fever or vomiting or headach has bowel and urinery incontinence since 1 week has myoclonus since 3 months has auditory hallucination and loss memory since 3 months past history : one attack of seizure before 8 month there is history of head trauma since 2 years the first syptom was before 9 month was speech disorder then after 2 weeks pt develop gait ataxia . MRI normal LFT and RFT normal CBC and serum electrolyte normal chest x ray normal doctors in my poor country cannot reach diagnosis please help in examination : reactive dilated pupil pt is aphasic Bp 90 on 60 afebrile no jaundice no pallor no cyanosis there is visual field defect positive plantar reflex bilateral knee reflexes are abscence in both no neck rigidity , negative kerng sign

### output:

I read the symptoms. The case has got complicated by trauma, convulsions,speech disorder and later ataxia. I would suggest doing blood gases study for now. Also know the pO2, pCO2 pH of blood. Bicarb level and base excess.Also, c reactive protein, ESR, mantoux, Also I would ask for a deeper history of hypoxia, anoxia, suffered any time during the seizure and brain injury.a decreased po2 at that time for 4 minutes is enough to damage the brain and keep the pupils reacting and dilated. A decreased serum sodium would suggest hyponatremia however subclinical gram negative infection must also be ruled out, esp tuberculosis and meningitis.(It's not always with a neck rigidity)