CPC Case for Febrary 8, 2005
Discussant: Dr. James Knochel, MD
Presenter: Dr. Rachel Dunagin, MD
Altered mental status
43 year old white female was brought the emergency room with a one day history of altered mental status. The evening prior to presentation her husband found her lethargic. Her mental status deteriorated over the next 6 hours, and she was described as acting “drunk.” She was stuporous, ataxic, and dysarthric, and vomited a few times. There was no history of fever, chills, headache, abdominal pain, or dysuria.
She has had three similar episodes in the past six months during which she rapidly improved with fluid, electrolyte, and bicarbonate supplementation.
|FH||Her mother and father died from coronary artery disease. Her siblings have diabetes mellitus, hypertension, diverticulosis, and migraine headaches. She denies any family history of hypercoagulable states.|
|She is married and has three children (ages 7, 10, 13). She started a new job in quality assurance 3 months ago but had been unemployed since the bowel infarction. She smoked 1 pack per day for 2 years in her 20’s. She has received blood transfusions previously. She denies alcohol or drug use, tattoos, occupational exposures, or recent travel.|
She reports losing approximately 100 pounds since her small and large bowel resection. She denies recent changes in diet, changes in bowel habits, hematochezia, melena, chest pain, arthralgias, rash, or sick contacts.
Vitals: Temp96.5 Pulse74 BP160/100 R24 SaO2 98%
General: Thin, middle-aged white female who is somnolent, lying in bed.
HEENT: Pupils were equal, round, reactive to light. Sclera anicteric. Extraocular movements are intact. Conjunctiva and mucous membranes are pink and moist. Fundi without papilledema. Oropharynx without exudates or lesions.
Neck: Supple, no lymphadenopathy, jugular venous distension, thyromegaly, bruits, or meningismus.
Chest: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops.
Abdomen: Thin, multiple scars, soft, nontender, nondistended, normoactive bowel sounds. Stool was yellow, guaiac negative.
Extremities: Warm, 2+ distal pulses. No lower extremity edema.
Skin: No rashes.
Neurological: She is somnolent and oriented x2. She moved all four extremities spontaneously and purposefully. Sensation was grossly intact to touch and pain. Patellar and biceps reflexes were 2+.
|A diagnostic test was sent, and a diagnosis was made.|