Senator Kennedy Collapses

With a seizure.  What are the possibilities?  Here is my differential diagnosis:

1. Progressive Tumor
2. Subtherapeutic levels on his seizure medication
3. Seizure despite therapeutic seizure medication; may need second or third medication
4. Electrolyte disturbance, usually in relation to hyponatremia
5. Stroke
6. Random chance
7. Alcohol intoxication or withdrawal
8. Other medications that can lower the seizure threshold, notably antibiotics like Levaquin
9. Infection in the brain such as encephalitis or meningitis or infection elsewhere such as a UTI, although much less likely to instigate a seizure
10. Traumatic injury or subacute fall that could cause an undiagnosed subdural hematoma.
11. Street drug use such as cocaine or methamphetamines.

That's my starting differential, in that order.  If I was Mr Kennedy's doctor tonight I would order an accu check, basic laboratories, blood counts, electrolytes, perhaps a TSH if he has known thyroid disease, drug screen, alcohol level.  A stat head CT in the ED as well to rule out acute bleed.  I would order an MRI if he has not had a recent one to better clarify his anatomy in the absence of bleed.  I would obtain all old records from his primary doc and neurologist and oncologist as well as prior operative reports.  I would check seizure medication levels, whatever they may be.  A detailed history to tweak out any changes in his life.  Sleep.  Caffeine.  Stress.  I would order prn ativan for further seizures.   I would examine him for any neurological deficits.  I would like to know his vital signs.  Atrial fibrilation?  Murmur?  Fever?  Rash? Jaundice? Hypoxemia?  Hypotension causes?   I would like to know a lot about his current clinical exam.

Once I had all my information, I would develop a plan.  Perhaps recurrent tumor required reevaluation with a surgeon and oncologist or radiation oncologist.  Perhaps consultation with a neurologist should additional medications be required.  If electrolyte disturbances are found, additional tests and fluid management would be indicated.  If he is found to be using cocaine, evaluation with a drug and alcohol intervention team would be initiated.  If he has other organ system failure, then further workups would be warranted.

Every differential requires a level of thought and evaluation.  Every abnormality on physical exam may add a level of complexity to the decision making.  When I walk into a patients room the chief complaint by itself will have a broad differential diagnosis without any further information.  As the history and physical examination progresses that differential is either narrowed down or expanded.  Sometimes the differential diagnosis is one condition.  Sometimes the differential diagnosis could be 100.  It is different for everyone.

The physicians differential will guide what the likelihood of the cause is and ultimately what tests to order.  Not all tests for all differentials are run immediately.  Common things to start.  Rare and esoteric conditions are evaluated if no answer is achieved.

If somebody asked Dr Happy what I would do if Mr Kennedy walked into the ER for admission, that's the answer they would get.  Now, where is that cook book I should be using...