Discussant: Mitch Carroll, MD.

Presenter: Jawad A. Qureshi,MD

CC: “I couldn’t get her up.” (The patient’s roommate)

HPI: The patient is a 45 yo WF with a h/o sinusitis who presented to the PHD ER obtunded. According to the roommate, the patient complained of sinus problems for 2-3 days prior to admission, and a headache and fever on the day prior to admission. The patient and the roommate had been drinking on the evening prior to presentation and the patient told the roommate that “if something happens to [her], please take care of [her] dogs.” The patient fell asleep on their couch and was “tossing and turning” throughout the night. At approximately 5 am, the roommate noted that the patient was more agitated and “would not wake up.” EMS was called and brought the patient to the PHD ER. Of note, EMS personnel found an opened, empty prescription bottle of skelaxin (metaxalone) in the patient’s apartment.
The roommate knows of no sick contacts, no history of attempted suicide in the past, no psychiatric illness history or other PMH, no medications that the patient was taking, and no other history of symptoms.

ROS: Unobtainable.

MEDS: Skelaxin, otherwise unknown.

ALL: Unknown.

PMH: Sinusitis, otherwise unknown.

PSH: Unknown.

FH: Mother passed 10 yrs ago (reason unknown). Father passed when the patient was 7 yrs old (reason unknown). The patient has no siblings.

SH: The patient is unemployed, lives with roommate, and has no living family members. The patient does smoke (duration and quantity unknown), and she is an occasional “heavy drinker.” No known IVDA or recreational drug use by the patient.

PE: VS: T 105.2 P 173 R 40 BP 123/75 Sating 95% on the ventilator

VENT: 700, R 14, FIO2 40, 98% O2

GEN: Obtunded, thin WF, intubated, intermittently shaking, biting ET tube,
diaphoretic, sheets wet with perspiration.

HEENT: NC, AT, Pupils 6 cm on R, 7 cm on L, sluggish, OP with ETT.

NECK: No JVD/LAD/TM.

CV: Tachycardic, normal S1 & S2, no M/R/G.

LUNGS: CTA Bilaterally.

ABD: S, NT, ND, hypoactive BS.

EXT: No C/C/E. 2+ distal pulses in the UEs and LEs bilat and symmetric.

NEURO: Intermittent tonic clonic movements of all four extremities, unable to
flex UEs or LEs secondary to rigidity; CN, muscle strength, and
sensation not testable secondary to the pt’s MS.

LABS:

OTHER STUDIES:

EKG: Sinus Tach, Rate 166, Normal axis, Normal intervals, No acute ST-T wave changes.

CXR: No acute cardio-pulmonary disease.

Head CT: Negative--No intracranial mass effect, acute intracranial hemorrhage, or hematoma noted.