CPC Case for January 22, 2004
Discussant: Dr. Feldman
Case presented by: Dr. Soni
Altered mental status
A 45 year old white female is brought to the ER for altered mental
status. Her father reports that her mental status has progressively declined
the past three days. She lives alone, and he went to check on her. He found
her to be very lethargic and confused. She was mumbling garbled words,
but could answer some questions appropriately. She also lacerated her lip
from a fall at home, and her father brought her to the ER.
(Synthroid) 200mcg daily
Citalopram (Celexa) 40mg in morning, 20mg in evening
Risperidone (Risperdal) 2mg twice daily
Carbamazepine (Tegretol) 200mg in morning, 400mg in evening
Nefazadone (Serzone) 100mg in morning, 400mg in evening
Hydrocodone + Acetaminophen (Vicodin 5/500) prn
|She is divorced and has three sons. She lives alone and is presently unemployed. She previously worked in an office as a secretarial assistant. She has smoked 1 pack per day for years. See HPI for alcohol and drug history. She has a tattoo on her right ankle. She has never received a transfusion.|
Vitals: Temp 97.5 Pulse 119 R16 BP 122/58 lying (BP 97/24 P145 standing)
Gen Overweight white female, confused and agitated
HEENT: Mild scleral icterus, 3 cm laceration of chin, dried blood in oropharynx, Poor dentition, dry mucous membranes
Neck: Supple without JVD, masses, bruits, or lymphadenopathy
Lungs: Clear to auscultation bilaterally
CV: Tachycardia with regular rhythm, II/VI systolic ejection murmur at right and left upper sternal borders without radiation
Abd: Soft, non-distended, mild tenderness to deep palpation in RUQ with voluntary guarding, liver span 8cm by percussion. Normal, active bowel sounds. No splenomegaly, fluid wave, or masses.
Ext: Asterixis present. No lower extremity edema or palmar erythema. Distal pulses 2+ bilaterally.
Neuro: Alert but not oriented. Cranial nerves II-XII intact. Motor 5/5 throughout and sensation grossly intact. DTR’s 2+ and Babinski downgoing.
|A diagnostic procedure was done and a diagnosis was made.|