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Common Consults

How to take a history, how to examine, and what to recommend
Seizure:

 

If known epileptic, goal is to determine AED regimen and compliance, seizure type/frequency and last seizure, epilepsy physician, any recent triggers (see below).  Check AED levels and if low or they are non-compliant, re-load; if not, consider increasing AED dose. Ask about prior AEDs tried.

  • RISK FACTORS: history of febrile seizures, family history of seizures, prenatal and perinatal complications, developmental delay, history of head trauma, history of CNS infection, history of CNS mass

  • TRIGGERS LOWERING SEIZURE THRESHOLD: medications, antiepileptic noncompliance, infection, metabolic abnormalities, toxic ingestion, menses, stress, sleep deprivation, EtOH / benzo withdrawal, bright lights or loud noise

  • CHARACTERISTICS: aura (visual, auditory, olfactory, epigastric rising sensation,  psychic (déjà vu, derrealization, depersonalization, fear, anxiety), type of seizure (especially how its starts), eyes open or closed, lateral eye or head deviation, length of seizure, associated tongue bite or other injury, incontinence, presence of post-ictal confusion, post-ictal weakness.

  • SUBTLE SEIZURE SIGNS: history of staring, automatisms, waking up incontinent or injured (tongue bite). myoclonic jerks.

Pay close attention to mental state, post-ictal paralysis or other focal deficits, subtle signs of ongoing seizures such as abnormal movements, head or eye deviation, eyelid twitching, pupillary abnormalities or hippus; also check for tongue bite / other injury, and check meningeal signs

WORKUP: AED levels, non-contrast head CT, basic labs including electrolytes and CBC, infectious workup (UA, CXR), tox screen, LP if concern for meningitis

  • AED: load and then standing dose if warranted

  • EEG:  for new onset seizure if EEG done within 24-48 hrs has highest yield.

  • MRI with and without contrast, seizure protocol if warranted

  • seizure precautions

  • ativan IV PRN seizure activity

  • evaluate medication list to see if anything lowers seizure threshold

  • no driving for 6 months per MA state law (self-report)

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Altered mental status:

 

  • Onset, Any precipitating factor, Baseline level of functioning (history of dementia?)

  • Recent infectious symptoms (dysuria, diarrhea / vomiting, URI symptoms)

  • Symptoms to suggest CNS infection (neck stiffness, headache, nausea)

  • Access to toxic ingestion / illicit substances

  • Associated focal deficits or abnormal movements

  • EtOH history

EXAM: full general exam with attention to signs of intoxication, dehydration and infection, neurologic exam including MMSE and paying close attention to level of consciousness, focus / concentration, focal neurologic deficits; also check and document meningeal signs, asterixis and look for subtle signs of seizure

 WORKUP: determined by above but typically includes

  • Fingerstick, Chem-7, Ca/Mg/Phos, BUN/Cr, LFTs, ammonia level, TSH, RPR, B12

  • Tox screen and alcohol level

  • Carefully review medication list for medications that can cause AMS

  • UA / UCx, CXR

  • Non-contrast head CT

  • +/- LP if fever / white count of unknown source, meningeal signs / symptoms, concern for HSV limbic encephalitis

  • EEG to r/o non-convulsive status and assess degree of encephalopathy

  • Determine and treat underlying cause, often multifactorial

  • Can consider IV thiamine empirically if malnourished or EtOH history

  • Supportive measures in acute delirium:  reorienting (clocks, calendars), familiar staff / family if possible, encourage sleep-wake cycles, visual and hearing aids if visually / hearing impaired

Differential of altered mental status:

  • Drugs

  • Endocrine, Electrolytes, Ethanol, Emotional, Eyes/Ears

  • Low O2, Lack of drugs, Liver

  • Infection

  • Retention

  • Intracranial (stroke/hemorrhage/mass), Ictal

  • Uremia, Under-nutrition, Under-hydration

  • Metabolic

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Headache:

 

  • New headache or personal history of headaches, and is this one different?

  • Location ? Quality ? Severity ? Onset (sudden or gradual)? Preceding aura?

  • Transient visual obscuration, especially with valsalva?

  • Associated features (nausea / vomiting / photophobia / phonophobia / diplopia / tinnitis)?

  • What and how much have they taken for the headaches?

  • Worsening factors (e.g. laying down, standing up, straining)?

  • Diurnal pattern (e.g. worse in the morning)?

  • OCP or Vitamin A / retinoid use? Recent weight gain?

  • Any patient recently postpartum or with systemic cancer, HIV, or taking immunosuppressive drugs should be assumed to have a secondary headache until proven otherwise

  •  

If chronic headache syndrome, ask about family history of headaches and screen for lifestyle factors: caffeine use, sleep, hydration status, frequency of analgesic use, relation to menses, stress, relation to weather

If new headache syndrome, screen for red flags: recent head or neck trauma, chiropractor visits, fevers or chills, recent travel or sick contacts, altered mental state, neck stiffness, focal neurologic or visual deficits

If associated visual changes in an older person, screen for GCA: fever, weight loss, jaw claudication, scalp tenderness, proximal limb myalgias, constitutional symptoms

  • Check vitals including temp and blood pressure. Full neurologic exam including Fundoscopic and visual fields, nuchal rigidity, focal neurologic deficits including Horner’s syndrome, scalp tenderness

If no red flags, can start treatment with:

  • IV hydration, Reglan 10 mg IV (or compazine). Can repeat q6h, benadryl/ativan to reverse akathisia

  • Toradol 30 mg IV (can repeat q6h, caution for renal disease)

  • Magnesium sulfate 2 g IV

  • Refractory: Depakote 1000 mg IV x 1, Solu-medrol 1 g IV x 1

If red flags present: LP, neuro-imaging, and/or ophtho consult

 

 

 

 

Spinal Syndromes:

 

HISTORY: Timeline and pattern of weakness and numbness, leg heaviness or warmth, back pain, trauma history, bowel or bladder symptoms, sexual dysfunction, perianal or saddle anesthesia, recent infectious symptoms, baseline ambulatory status.

EXAM: In addition to standard exam, check pinprick and vibration on both sides of spine to assess for spinal cord sensory level, palpate / percuss for paraspinal tenderness, rectal exam  for perianal sensation and anal sphincter tone, palpate bladder, carefully assess muscle tone, skin exam for rash if you suspects an inflammatory disorder,  pay attention to DTRs (triceps C6-7, biceps C5-6, brachioradialis C5-6, knee L2-4, ankle S1) and cutaneous reflexes (upper abdominal T8-10, lower abdominal T10-12, plantar L5-S1) as well as check Hoffman’s and Clonus

DIFFERENTIAL: Herniated disc, myelitis, spinal tumor, AIDP (if reflexes are lost), neuropathy, neurosarcoidosis, syringomyelia.

 

CORD TUMORS: Extramedullary (outside cord) may be intradural (meningiomas and schwannomas) or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas).   Intramedullary are rare and usually gliomas (astrocytomas or ependymomas), in children usually low-grade astrocytomas.

WORKUP :

  • PVR with bladder scan or catheter for urinary retention

  • If you suspect acute cord compression, conus or cauda equina syndrome – this is a surgical emergency! Give dexamethasone 10 mg IV x 1, call spine service immediately (alternates between trauma and neurosurgery) for decompression, get STAT imaging

  • MRI spine w/wo, choose appropriate level; include diffusion if you suspect ischemia

  • Based on above, consider:  Brain MRI for MS plaques; serum RPR, copper, B12, NMO Ab, ACE, ESR, ANA, Lyme, HIV, HTLV-1, Mycoplasma, hep panel; CSF for basic studies and AFB / TB cx, crypto ag, fungal stain/cx, viral PCR, Lyme, VZV, EBV, CMV, enterovirus, ACE, HHV-6/7, WNV

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Cord syndromes:

 

Brown-Sequard: Hemisection leading to ipsilateral dorsal column signs, contralateral spinothalamic signs, usually spared bladder function.

Central cord: Segmental pain and temperature loss, segmental DTRs lost, segmental weakness/atrophy, UMN signs below the lesion, urinary urgency

Extrinsic compression: Segmental symptoms indicate nerve root involvement, long tract findings (UMN signs, numbness, weakness, urinary urgency) indicate cord involvement. Pain and temperature loss begins sacrally.

Spondylotic myelopathy: From disc disease or osteophytes, begin with segmental findings such as dropped reflexes at the level of the lesion and spastic weakness with hyperreflexia below the lesion, sensory findings usually come later.

Conus medullaris: Sudden, bilateral, symmetric, spastic distal lower extremity weakness, loss of ankle jerks, low back pain, perianal numbness, early onset of urinary retention and overflow incontinence, impotence.

Cauda equina: Flaccid lower extremity weakness, urinary retention late in the disease, decreased anal tone, occasional sexual dysfunction, saddle anesthesia, loss of knee and ankle reflexes, severe radicular pain, presentation may be asymmetric and gradual.

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Dizziness:

 

  • Onset?

  • Description of symptoms (lightheadedness, room spinning, walking on a boat)

  • Severity, Duration (brief episodes, long episodes, or constant)

  • Worse with head turning or getting up?

  • Nausea or vomiting?

  • Headache or neck pain?

  • Chest pain or palpitations?

  • Recent head or neck trauma or neck manipulations?

  • Associated ear pain, URI symptoms, aural fullness, tinnitus?

  • Hydration status?

  • Able to walk?

  • Feel off balance or pulled to one side?

  • Associated neurologic deficits, especially ataxia and brainstem symptoms (diplopia or other visual changes, tongue heaviness, taste changes, changes in voice, trouble chewing or swallowing

Check orthostatics if indicated, physical exam including otoscopic exam, full neurologic exam including detailed brainstem exam (include taste, LT and PP sensation of face, gag, tongue and uvula deviation, skew deviation of eyes), nystagmus (direction, extinguishing or not), head impulse test, Dix-Hallpike test, as well as cerebellar testing and gait exam.

If there are red flags or you cannot rule out central etiology, obtain neuro-imaging such as non-contrast head CT, CTA neck up to circle of Willis, and admission to rule out posterior circulation stroke. Following admission, obtain MRI to rule-out stroke.

                        If no red flags and symptoms suggest BPPV or other benign etiology:

  • IV fluids

  • Meclizine (25-100 mg/day in divided doses) or Valium (5-10 mg q3-4 hr PRN)

  • Antiemetic (raglan or zofran)

  • Teach Epley maneuver and give them a handout or PT for vestibular rehab

 

HINTS exam (for actively vertiginous patients only):

 

  1. Head impulse test of vestibulo-ocular reflex function

  2. Observation for nystagmus in primary, right, and left gaze

  3. Alternate cover test for skew deviation.

Head Impulse Test:

  1. Normally, a functional vestibular system will identify any movement of the head position and rapidly correct eye movement accordingly so that the center of the vision remains on a target. This reflex fails in peripheral causes of vertigo effective the vestibulocochlear nerve

  2. Have patient fix their eyes on your nose

  3. Move their head in the horizontal plane to the left and righ

  4. When the head is turned towards the normal side the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target

  5. When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a corrective saccade to re-fixate on the visual target [1][2]

  6. It is reassuring if the reflex is abnormal (due to dysfunction of the peripheral nerve)

Test of Skew

  • Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.

  • Skew is also known vertical dysconjugate gaze and is a sign of a central lesion

  1. Have pt look at your nose with their eyes and then cover one eye

  2. Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.

  3. Repeat with on each eye

This test is 100% sensitive and 96% specific for central lesion. Higher than brain MRI.

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