ZSFG AM Report 7/5 Pearls: Coma exam, Serotonin Syndrome vs NMS, HCC screening

Thank you, Katie, for discussing the case of a 64W h/o bipolar disorder on various psychoactive meds, admitted for subacute onset rigidity, increased tone, diaphoresis, whose prolonged workup led to a diagnosis of catatonia.

***Prepare yourself for clinical pearls in table form***

When someone is not responding or participating with your exam, you can adjust your neuro exam to be more in line with a brief Coma Exam:

  • CN exam: pupil, corneal, gag, VOR or oculocephalic maneuver, cold calorics (see pic below)
  • GCS (motor testing is strongest predictor of outcome)
  • Reflexes
  • Tone

brainstem exam doll

For this case, one could narrow the framework for AMS+fever to focus on medications…

ams and fever

For serotonin syndrome (SS), think “hot and fast” as discussed today in report and as reflected in the following table diagnostic criteria for SS:

hunter

To compare and contrast serotonin syndrome and neuroleptic malignant syndrome further:
nms serotoin

From the Ditty:

Anisocytosis: anemia with RBC’s of unequal/abnormal SIZE

anisocytosis

Poikilocytosis: anemia with RBC’s of unequal/abnormal SHAPE

Poikilocytes

HCC screening and mortality reduction…

While the recommendations by the AASLD is to do ultrasound alone q6months (AFP w/ lower sensitivity/specificity) for folks at high risk (see table and article below), the minimal study evidence that exists out of China showed reduction in mortality (37%, Zhang et al 2004) for screening with AFP and ultrasound.

hcc surveillance

References:

 

Evernote link: https://www.evernote.com/shard/s354/sh/cfa249b5-de74-46e7-ba2d-78c0115afe4e/28f3efec44aa2afb8a17b78650a3a289

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