58-year-old woman with obtundation and subtle twitching
A 58-year-old woman with systemic lupus erythematosus and stage 3 chronic kidney disease is hospitalized for evaluation of syncope. On hospital day 2, she becomes progressively obtunded. Her initial non-contrast head CT was unremarkable. A visiting family member reports observing intermittent, subtle twitching of the patient's left eyelid and fingers. Temperature is 37.1 C, blood pressure 145/88 mmHg, heart rate 92/min, respirations 16/min, and oxygen saturation 96% on room air. She opens her eyes only to painful stimuli and does not follow commands. Laboratory studies show BUN 58 mg/dL and creatinine 2.9 mg/dL (baseline 2.5 mg/dL). Electrolytes and glucose are normal. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
Finished your notes? Time to swap the pager for a crown. Kingdoms of Silent Sorrows is the ultimate 'brain-break', a high-stakes fantasy featuring a Fae princess, a Vampire king, and an enemies-to-lovers arc that will actually make you forget about your rounding list. No p-values, just fated mates and forbidden magic.
View on AmazonThe Correct Answer
B
Explanation
Clinical Pearl:
Non-convulsive status epilepticus (NCSE) should be suspected in any patient with unexplained altered mental status, particularly with subtle motor signs like facial twitching or myoclonus. The diagnosis is confirmed with continuous electroencephalography.
Explanation:
This patient's presentation of progressive, unexplained obtundation with subtle myoclonic jerks is highly suspicious for non-convulsive status epilepticus (NCSE). The most appropriate next step in management is to obtain continuous electroencephalography (EEG), which is the definitive diagnostic test for this neurologic emergency. While magnetic resonance imaging of the brain could identify structural abnormalities or inflammation related to her lupus, and a lumbar puncture could assess for infection or CNS lupus, the acute twitching makes seizure activity the most pressing concern that must be evaluated first. Empiric treatment with intravenous lorazepam is premature without a diagnosis, as it can worsen non-epileptic encephalopathy and confound EEG interpretation. Measuring the serum ammonia level is a low-yield step in a patient without known liver disease; while her mild uremia could contribute to altered mental status, it does not explain the new focal motor signs.
See you tomorrow morning!