 Introduction

The brain primarily utilizes glucose as its source of energy. However, in low glucose states, the
brain can utilize

 Case description
A 55-year-old female with complex medical history including recent anoxic brain injury status
post cardiac arrest and, CVA, and remote baseline history of seizure disorder presented to the
outpatient family medicine clinic complaining of “tremors” after ingesting colonoscopy bowel
prep solution. Prior to presentation to the clinic, the patient had not anything to eat and only
water to drink for approximately a day and a half prior to starting the bowel prep. After
ingestion of the first dose of the bowel prep, the patient started experiencing “tremors”. The
patient ingested the second dose as instructed and the patient’s “tremors” increased in
frequency and amplitude. The patient’s mother called EMS due to concerns about patient’s
hypertension and seizure history. However, patient declined transportation to the emergency
department.

Upon physical exam, patient was hemodynamically stable. Neurologic exam showed bilateral
upper extremity and facial myoclonus that worsened with deliberate movement. Due to the
severity of the myoclonus, the patient’s complex medical history, and concern for possible
electrolyte disturbance, the patient was advised to report to the emergency department.

In the emergency department, the patient’s CBC, CMP, magnesium, phosphate, and ammonia
labs were all within normal limits. Inpatient service was consulted to the ED and after speaking
with the patient and reviewing labs, the hospitalist ordered a normal diet for the patient. Once
the patient started eating, the patient’s myoclonus decreased dramatically, nearly resolving.
The inpatient team hypothesized that patient’s myoclonus might be due to patient’s fasted
state leading to fasting ketosis. Since the patient had a hypoxic ischemic brain injury within the
last 6 months, the inpatient further hypothesized that the patient’s brain was not able to
efficiently utilize ketones as a metabolic source, leading to mycolonus. Neurology was also
consulted and agreed with the inpatient team regarding the fasting ketosis metabolic
disturbance hypothesis.

Patient was admitted overnight for observation. Patient improved and was discharged from the
hospital.

Upon 1 day follow up, the patient’s myoclonus had completely resolved. We advised the
patient to not schedule a colonoscopy for another 6 months. We also suggested utilizing a clear
liquid meal replacement for the bowel prep in order to prevent recurrence of myoclonus.

 Discussion of practice guidelines

 Conclusions/discussion
 References (Reference page may be in addition to the five-page maximum)