EM Forum Case #144 "Difficult 'jerk' diagnosis."
by Charlene Babcock Irvin, MD, FACEP  

A 21 y/o male presents with possible seizure. According to EMS they were called for person down. Mom noted her son passed out, and then had some shaking. His family witnessed the event, and his brothers helped him to the ground so he did not strike his head very hard. EMS arrived and noted he was still confused and very diaphoretic. His mom notes he has a history of pseudo seizures. He had another episode just like this last week, and went to another Emergency Department, and was loaded with Dilantin. They did a CT of his head, and it was normal. His mother notes he has had seizures for `many years' and has been on numerous anticonvulsants. He states he just `feels funny' then passes out. When he comes to, they tell him he had a seizure. His mother notes he gets sweaty, then drools, then falls. While on the ground he does jerk some. Then eventually he wakes up. One doctor told them he has pseudo seizures. He had no tongue biting, and no incontinence.

PMH: Negative except for seizures or pseudo seizures.
FH: Neg
ROS: Neg
Meds: Dilantin, but he admits to not taking it.
Allergies: None
PE: RR=20, Blood pressure 120/85, Pulse 140, Temp 98.9F, Sat 96% (RA)

Obese male (BMI=30.5) in no distress. Neurologically non-focal, except for mental status exam and his tachycardia. He's oriented x3, but slow to answer. He can follow commands, but has difficulty putting words together into a sentence. Per mother, this is his baseline.

Labs: Dilantin: 5.9 mcg/ml, Basic Metabolic panel normal except C02=17, Glu=137, WBC=14.4, Hbg=14.8. EKG: Sinus Tachycardia, non-specific ST changes (T wave flattening in inferior leads).

He is loaded with Phenytoin, but continues to have persistent sinus tachycardia. Repeat vital signs 3 hours later: RR=24, BP=123/87, HR=138, Sat=99% (RA).

Questions:

1. What should you consider as the causes of the tachycardia?

2. What is your disposition?

3. Do you need a CT scan?

4. What BMI is considered obesity?


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