Nonfocal Examination Research Articles

A 17-Year-Old Girl With Weight Loss and Elevated Inflammatory Markers

A 17-year-old girl presented to her primary care physician with a history of unintentional weight loss and vague sensory symptoms, including tingling of her lower extremities. She had a nonrevealing neurology workup and a largely normal rheumatology workup apart from mild elevation in her inflammatory markers. She also had a nonfocal examination apart from a posterior cervical lymph node (2 × 1 cm). Given that she was well appearing, with a nonfocal examination and only mild laboratory abnormalities, she was told to follow-up with rheumatology in 3 months. Around that time, she re-presented to her medical home for a well-child visit, during which she was noted to have continued weight loss, now amounting to 17 lb in 1 year, and marked further elevation in her inflammatory markers. Her laboratory results were also significant for a profound microcytic anemia requiring inpatient admission for blood transfusion. During her admission, she was seen by the rheumatology, gastroenterology, and oncology subspecialty teams. Despite imaging studies and extensive laboratory workup, there was no unifying diagnosis at the time of her hospital discharge. Ultimately, an outpatient imaging study revealed the etiology.

Clinical utility and cost analysis of routine postoperative head CT in elective aneurysm clippings.

OBJECTIVE Postoperative head CT scanning is performed routinely at the authors' institution on all neurosurgical patients after elective aneurysm clippings. The goal of this study was to determine how often these scans influence medical management and to quantify the associated imaging costs. METHODS The authors reviewed the medical records and accounting database of 304 patients who underwent elective (i.e., nonruptured) aneurysm clipping performed by 1 surgeon (M.T.L.) from 2010 to 2014 at the University of California, San Francisco. Specifically, the total number of postoperative head CT scans, radiographic findings, and the effect of these studies on patient management were determined. The authors obtained the total hospital costs for these patients, including the cost of imaging studies, from the hospital accounting database. RESULTS Overall, postoperative CT findings influenced clinical management in 3.6% of cases; specifically, they led to permissive hypertension in 4 patients for possible ischemia, administration of mannitol for edema and high-flow oxygen for pneumocephalus in 2 patients each, seizure prophylaxis in 1 patient, Plavix readjustment in 1 patient, and return to the operating room for an asymptomatic epidural hematoma evacuation in 1 patient. When patients were stratified on the basis of postoperative neurological examination, findings on CT scans altered management in 1.1%, 4.8%, and 9.0% of patients with no new neurological deficits, a nonfocal examination, and focal deficits, respectively. The mean total hospital cost for treating patients who undergo elective aneurysm clipping was $72,227 (± $53,966) (all values are US dollars), and the cost of obtaining a noncontrast head CT scan was $292. Neurologically intact patients required 99 head CT scans, at a cost of $28,908, to obtain 1 head CT scan that influenced medical management. In contrast, patients with a focal neurological deficit required only 11 head CT scans, at a cost of $3212, to obtain 1 head CT scan that changed clinical management. CONCLUSIONS Although there are no clear guidelines, the large number and high cost of CT scans needed to treat neurologically intact elective aneurysm patients suggest that careful neurological monitoring may be more clinically useful and a better use of hospital resources than routine postoperative CT.

Frequency of acute changes found on head computed tomographies in critically ill patients: A retrospective cohort study

PurposeThe frequency of positive findings on computed tomography (CT) of the head in critically ill patients who develop neurologic dysfunction is not known. Materials and methodsCohort study of head CTs for patients admitted to 3 intensive care units from 2005 to 2010. We documented the frequency of acute changes for all head CTs and for the subgroup of patients with altered mental status (AMS). We also examined associations between patient characteristics or medications administered before head CT and the odds of an acute change on head CT using multivariate logistic regression. ResultsDuring 11 338 intensive care unit admissions, there were 901 eligible head CTs on 706 patients (6% of patients). Among head CTs, 155 (17.2%) assessed concern of new focal deficit, 99 (11.0%) concern for a seizure, and 635 (70.5%) for AMS. Acute changes were found on 109 (12.1%; 95% confidence interval [CI], 10.0%-14.2%) of all head CTs, and 30% (22.4%-36.9%) of patients with focal deficits, 16.2% (8.8%-23.5%) of patients with seizures but only 7.4% (5.4%-9.4%) for patients with AMS. A diagnosis of sepsis was associated with a decreased odds of an acute change on head CT for all head CTs (odds ratio 0.61; 95% CI, 0.40-0.95; P = .028) but was not significantly associated with a decreased risk among the cohort of head CTs for AMS (odds ratio 0.82; 95% CI, 0.41-1.62; P = .56). No other factors were associated with an altered risk of acute change on head CT for all patients in our cohort or for those with AMS. ConclusionsAcute changes on head CTs performed for concern regarding new focal neurologic deficit or seizures are frequent compared with those performed for AMS with a nonfocal examination. No specific patient characteristics or medications were associated with a large change in the likelihood of finding an acute change for patients with AMS.

Clinical Reasoning:

An 18-year-old man was brought to the emergency department (ED) by his parents because he was “not himself.” Two days prior, he woke with a bloody tongue and no memory of biting it, decreased appetite, fever, and fatigue. His parents observed him to have impaired short-term memory, “jerky” flexion-extension movements of the arms, visual hallucinations, and confusion. There was no recent travel, illness, animal or insect bites, prolonged outdoor exposure, or tobacco, drug, or alcohol abuse. He was afebrile with normal vital signs. There was bradyphrenia, poverty of speech, deficits in short-term memory, and poor attention. Cranial nerves, deep tendon reflexes, coordination, gait, strength, and sensation were normal and symmetric with downgoing toes. No abnormal movements were observed in the ED. Complete blood count, comprehensive metabolic panel, urine drug screen, and noncontrast head CT scan were normal. A lumbar puncture was performed and CSF analysis showed 23 white blood cells with 86% lymphocytes, 14% monocytes, 0% neutrophils, 187 erythrocytes, protein 46, glucose 94. ### Questions for consideration: 1. What treatable diagnosis is at the top of the differential? 2. What diagnostic studies and empiric therapies should be considered? Herpes simplex virus (HSV) encephalitis should be the primary concern and CSF was sent for HSV 1 and 2 PCR. MRI of the brain with gadolinium was normal. He was treated with acyclovir in the ED and phenytoin was started for what was thought to have been a seizure at home. On the second day of hospitalization, he had a nonfocal examination, but became aggressive and violent, had constant visual hallucinations, and only recognized his mother. Psychotic behavior persisted for several days and he was started on haloperidol. An EEG showed diffuse slowing. HSV PCR of the CSF was negative, but acyclovir was continued. On the fifth day, he exhibited hypersalivation and chewing movements, and was nonverbal. His …

Predictors of success for drug discontinuation following neonatal seizures

Guidelines for the discontinuation of antiepileptic drugs in neonatal seizures are not well defined. Some studies suggested possible criteria for antiepileptic drug discontinuation but no precise criteria have emerged. We performed a retrospective analysis of 58 infants with neonatal seizures during a 3 year period. Antiepileptic drugs were discontinued when patients were seizure-free for 3 months, had normal electroencephalography initially or at subsequent examination, and had a nonfocal examination. Normal initial electroencephalography was demonstrated to be a reliable predictor for discontinuing antiepileptic drugs successfully in 18 of 22 term infants; normal subsequent electroencephalography was a reliable predictor of successful discontinuation of antiepileptic drugs in 9 of 10 premature infants.