Lethargy

Chief Complaint: A 14 year old girl on your inpatient Rehabilitation unit sustained a moderate-to-severe TBI with a subdural hematoma requiring craniotomy. Her therapist calls you to the gym and tells you that today she has been more drowsy and lethargic than usual.

DOMAIN A: DATA ACQUISITION

+ What are the relevant components of this patient’s history and physical examination, and why?

Relevant History:

  • What is the time course of the change in mental status? Describe what has changed this morning.
  • What are the circumstances surrounding the patient’s initial TBI (mechanism of injury, time since injury, other concomitant injuries)?
  • Describe the patient’s hospital course including labs and imaging.
  • Describe the patient’s recent baseline neurologic status in greater detail.
  • Recent vital signs?
  • Past medical and surgical history?
  • Current medications and recent medication changes?
  • Any risk for recent substance abuse?

Relevant Physical Examination:

  • Vital signs?
  • General appearance?
  • Examination of surgical incision on scalp?
  • Arousal (is the patient attentive; do her eyes open with or without stimulation?)
  • Communication (any attempts at intentional communication?)
  • Command following?
  • Verbalizations or oral movements?
  • Movement of extremities (spontaneous or purposeful?)
  • Object use?
  • Visual pursuit, fixation, or startle?
  • Withdrawal to pain?
  • Within the limits of command following, cranial nerve examination, manual muscle testing, sensory examination?
  • Reflexes and tone/spasticity?
  • Additional examination: heart, lungs, abdomen, extremities
 

DOMAIN B: PROBLEM SOLVING

You learn that the patient has recently been confused and agitated, but it was difficult to wake her up today and she has been drowsy all morning. On examination she is oriented only to self and briefly follows simple one step commands, but she only sustains attention for a few seconds at a time before falling back asleep, and does not participate in manual muscle testing or the remainder of your neurologic examination.

+ What is your differential diagnosis for this change in mental status?

  • My primary concern would be new or worsened intracranial pathology, including new or worsened intracranial bleed, hydrocephalus, seizures, or postoperative intracranial infection. Given her history of recent TBI with craniotomy, she is at high risk of developing any of these conditions and I would want to rule these serious conditions out first.
  • Infection would also be high on my differential diagnosis. I would be most suspicious of UTI, pneumonia, surgical site infection, or bacteremia/sepsis.
  • Medication toxicity is also on my differential, as is illicit substance abuse or withdrawal.
  • I am also concerned about possible metabolic disturbance including electrolyte abnormalities or hypoglycemia, hypercarbia from respiratory failure, or severe anemia.

+ Challenge Question

  • What other metabolic abnormalities could cause altered mental status?

+ Challenge Answer

Some of the most common include:

  • Hypoglycemia or hyperglycemia
  • Hyponatremia or hypernatremia
  • Hypocalcemia or hypercalcemia
  • Uremia
  • Thyrotoxicosis or myxedema coma
  • Thiamine deficiency

+ What initial tests would you order?

  • The patient is unable to provide a history, so a broad workup would be appropriate. I would start with a CT of her head and a stat fingerstick glucose level. I would also order CBC, CMP, urinalysis, blood cultures, EEG, and chest x-ray. If she is on seizure medications then I would obtain levels of those medications. I would consider obtaining free T4, TSH, and vitamin B12 levels.
 

DOMAIN C: PATIENT MANAGEMENT

CT scan reveals new hydrocephalus and the remainder of her workup is unremarkable. Her mental status is unchanged.

+ What steps would you take next?

  • I would call neurosurgery as quickly as possible to facilitate transfer to their service for possible neurosurgical intervention. In the interim I would ensure close monitoring of her vitals and “A.B.C.”s of her airway, breathing, and circulation. I would reach out to her POA to inform them of this new diagnosis and transfer.

+ Challenge Question

  • Broadly speaking, what type of neurosurgical intervention would you expect in this patient with hydrocephalus?

+ Challenge Answer

  • I would expect the neurosurgery team to place some type of drain or shunt to relieve the increased intracranial pressure, such as an EVD (external ventricular drain), VPS (ventriculoperitoneal shunt), or possibly a lumbar drain.
 

DOMAIN D: SYSTEMS-BASED PRACTICE

Neurosurgery places a VP shunt and the patient improves to her neurologic baseline of Ranchos level 4 (confused and agitated). You see her as a consultant and recommend readmission to inpatient rehabilitation, however insurance denies this due to her agitation, stating that she is not an appropriate candidate because she cannot participate in therapies. You are offered a peer-to-peer conversation to appeal this conversation.

+ Would you agree to participate in the peer-to-peer conversation with the insurance company?

  • Yes, I believe that that would be best for the patient.

+ What would be some of the main points that you would like to get across in the conversation? As a reminder, the insurance company has denied the patient since they believe that her agitation precludes her from participating in therapies.

  • I would focus on four major points: 1) education on brain injury, 2) therapy goals for an agitated patient, 3) benefits of inpatient PM&R management, 4) patient safety
    1. I would be sure to acknowledge that being confused and agitated is a natural and normal part of recovery from brain injury. I could perhaps reference the Ranchos Los Amigos scale to educate the reviewer on brain injury recovery.
    1. I would emphasize the types of therapies that she would be receiving and how this could benefit her and promote her recovery. If possible, I would go back to some of the therapy documentation from her initial rehabilitation admission to give some concrete evidence of how she can participate and progress even if agitated.
    1. I would discuss the benefits of having a PM&R-trained physician manage her agitation both pharmacologically and non-pharmacologically.
    1. I would highlight the inpatient rehabilitation unit’s capability to handle this sort of patient. She is currently a danger to herself and others and an inpatient rehabilitation unit would be a safer option than home or a subacute rehabilitation facility.
 

DOMAIN E: INTERPERSONAL AND COMMUNICATION SKILLS

You have noticed that your 14-year-old brain injured patient’s agitation improves when her mother comes to visit but worsens when large groups of friends or family come to visit her in the evenings. You set a new restriction that only two people can visit at a time. The next time you see her mother (who is her designated POA), she tells you that she is unhappy with the rule since her daughter “needs her whole family right now.”

+ How would you respond?

  • “Thank you very much for accommodating this new change in her care plan. I understand that this is a big sacrifice for you and for your family. I think we all agree that what we want most is your daughter’s recovery. We have found that most people with your daughter’s condition do best in a ‘low-stimulation’ environment and that even small things like TVs or radios or bright lights can be very distracting. We want to let her brain focus on recovering rather than focusing on everything going on in her room. We are doing our best to keep her room quiet and peaceful and we appreciate the help from your family in doing so, even if it means that she cannot have too many people visit at once. I want to assure you that we have made this decision with your daughter’s best interests in mind. Please let us know how we can support your family in this.”
  • Note: You should be sure to be empathetic, but should not cave to pressure to change your decisions if you believe that they are what is best for the patient. You should explain yourself in ways that are simple and easy to digest. Try your best to be cool and collected and avoid confrontation whenever possible.