CPC Case for January 22, 2004

Discussant: Dr. Feldman
Case presented by: Dr. Soni

CC

Altered mental status
HPI

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 over 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.
 
Her father reports that she attends Alcoholics Anonymous meetings twice weekly, and has abstained from alcohol for 2 years. She has used intravenous cocaine and marijuana in the past but none recently. She takes hydrocodone + acetaminophen (Vicodin) as needed for lower back pain, but it is not known how much she has taken recently. Her father denies any new medications or suspicion for suicide.
PMH
  1. Bipolar Disorder: She has been stable and is followed at the Denton MHMR.
    • Her psychiatrist reports that her routine labs were normal, and she was doing well in December of 2002
  2. Hypothyroidism-Diagnosed with Grave’s disease in 1989, treated with radioactive iodine twice
  3. Alcoholism-see above
MEDICATIONS Levothyroxine (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

SH

 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.           
ALLERGIES NKDA
FH

Mother 73, osteoarthritis, hypothyroidism
Father 74, coronary artery disease s/p CABG
Brother 47, coronary artery disease
Brother 44, hypothyroidism
Sister Died at age 14 from fulminant hepatitis
Sons: Healthy
ROS

Vitals: Temp 97.5 Pulse 119 R16 BP 122/58 lying (BP 97/24 P145 standing)
 

PHYSICAL EXAM:

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.

LABS:
Na
137
K
 3.2
Cl
 103
HCO3
 20
Glucose
 118
BUN
 49
Creatinine
 3.3
Ca
8.2
Mg
 1.7
Phos
 2.3 (2.5 - 4.5)
 
 
 
Alk Phos
 253
AST
2233
ALT
3539
TP
6.2
Alb
 3.0
Total Bili
5.5
Globulins
 3.2
APA
 neg
NH3
 59(9-33 micromole/L)
Ceruloplasmin
 21(20-60)
Carbamazeine
 10.6 (therapeutic 4.0 - 10.0)
HBsAg
 neg  
HbsAb
neg    
HAV IgM
 neg    
Anti-HCV
 neg  
Hep E IgM
 neg
WBC
10.1
Hgb
 12.3
Hct
 35.6
 
 
 
 
   
Coag:
 PT 26.3— INR 2.1

UA: amber, hazy / s.g 1.023/ pH6.5/ prot 30/ ketone 15/ nitrite +/ bili small/, urobil >8.0/ WBC 17/ RBC 8/ bact moderate
Tox: + opiates
CXR: normal
Blood Cx's neg
CT Head: Normal
EKG: Normal sinus rhythm
Abdominal Sono: cholelithiasis, mild fatty infiltration
 

 
  A diagnostic procedure was done and a diagnosis was made.