Merry Christmas, it’s a Neuro Kind of Night

Neurology has always freaked me out. It’s so meticulous and nitty gritty. Ugh. Last night I received an admission and on the chief complaint portion of our EMR it said “seizure, neuro says SCU”. I was up to do the next admission. I’m not going to lie, I’ve never previously done an admission for a seizure and I didn’t really deal with anything neurological in my first job. The closest I got to that was taking care of post op patients who had had lumbar or cervical laminectomies (aka not even close).

So, the first thing I did was pull out my iPad to read a little. Where I work the PA’s have a nice office and there is ample room to have your things that you need which is nice. So, not that I had NO CLUE how to approach a patient with a possible seizure (he ended up being more AMS as well but I’ll get to that)– but I didn’t want to miss anything.

I started by reading the neurology consult–which was helpful from a history standpoint, but it seemed to me like they just assumed he had a seizure becuase he had a history. Hey–they’re neurologists it is their job to look at the brain. I took a bit more broad perspective. But first, let me tell you about the patients background so you can get a bit more clear picture.

Pt was elderly, medical history of MR, schizophrenia, seizure disorder and hypothyroidism. I read carefully through his chart and once I had my bearings and an outline of a plan I went to the ED to see him. At this point he was unaccompanied (he had previously been brought in by a family memeber that helps to care for him). I tried to arouse him just by voice and he stirred a bit but couldn’t stay with me, if you will. I shook him a bit and he would open and close his eyes on and off–he couldn’t follow my directive to open his eyes in order to examine his pupils. I tried asking him a couple of questions and the most I got out of him were slurred noises (his head CT was clean by the way). His tounge was moving in odd patterns. Exam was otherwise insignificant. The most important information at this time came from the caregiver. She had left at this time, but I called to speak with her over the phone.
My interview with her revealed that the patient had not been acting like himself for approximately 10 days. Increased speech, talking to dead relatives and on the same day of admission 2-3 episodes of bowel and/or bladder incontinence. In addition to this information I also inquired about how the patient had been sleeping, eating, drinking, new medications or modifications, also if he took care of his own medications if he could have possibly taken too much of something (ASA, tylenol–or was he drunk–hey you can’t discriminate in medicine I ask 80 year olds all of the time if they do illicit drugs). I should also add that he had not been taking one of the seizure medications he was previously prescribed–we aren’t quite sure why–there’s a hole in the system somewhere. His other antiseizure medication level came back WNL (within normal limits). There were other things I asked in my HPI–but those are the most important.
The ED board originally made me think it was a slam dunk tonic-clonic seizure; however, at this time my ddx (differential diagnosis) was a bit more than just seizure. My ddx included seizure, toxcicity, CVA/TIA, retained CO2, elevated NH3, myxedma coma, dehydration and lactic acidosis. Basically your differential for AMS.
My work up included:
Head CT (which was already performed and negative for acute process)
UA- UTI in the elderly can cause what looks liek AMS or delerium
ABG for retained CO2
TSH/FT4–pt demonstrated subclinical hypothyroidism which means his TSH was elevated but T4 measure was normal (so basically its a big “whoop-de-do”
Urine tox screen
Tylenol level
Salicyilate level
NH3 level
Since the patient required assistance with medications first you never know what people can get into and just take a bunch of something–also as nice as the woman I talked to on the phone seemed I don’t necessarily trust anyone–I saw one too many lifetime movies and unsolved mysteries as a kid–so yes I considered poinsoning. Oh, I also checked ethanol and methanol levels as well. (FYI I’ve read that you can actually treat methanol toxicity with ethanol–not exactly how true it is but interesting concept that I need to look into more). And of course I also did a seizure work up including long term eeg monitoring, prolactin level, calcium level, neuro checks q2h. Oh, the last thing that I thought was strange and I need to look into this more is that my Attending Phsycian did disagree with one of my orders– not to provide prn ativan for seizure activity because they would want to catch it on the eeg monitor. However, obviously if he were to go into status treatment would be required and address at the time if that situation were to arise.
At this point his workup is still negative. I did place him on continual EEG monitoring which to my knowledge has yet to reveal anything. So, I’ll be interested to see what his workup shows and what the specialists have to say about his condition.
My post has several points: 1. I don’t like neuro. 2. Don’t trust what someone else says about a patient. Keep an open mind for your ddx just becasue someone else says it’s true doesn’t mean anything. 3. I hope you all learned something about the broad work up for AMS/seizure.
My second admission of the night was actually neurological related as well–I guess it was time for me to get comfortable with the uncomfortable.

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