Question

Clinical Scenario:

CHIEF COMPLAINT: Acute Altered Mental Status

HISTORY OF PRESENT ILLNESS: Mrs. X is a 56-year-old Caucasian female with medical history notable for chronic pain and polypharmacy. Beginning three days ago she felt as though she had a flu-like illness. The symptoms began with a cough 3 days ago, then progressed to a feeling of fatigue 2 days ago, and then 1 day ago she became confused. She has been barely verbal and unable to communicate with her family. The family continued to watch her at home and on the day of presentation to the ED she had not gotten any better and they brought her in for further evaluation. Today on the day of presentation she had an onset of diarrhea (no blood or melena in stool) and was acting strangely at home. She was walking around naked and taking out her dentures and continued to be nonverbal. She has not had anything to eat or drink since the onset of her illness and has not taken any of her medications. The family reported that she has felt feverish and has been weak. She has had a 25lb weight loss over the last 2 months from taking hydroxycut. The family expressed concern for the overuse of narcotic medications. They reported that Mrs. X took 80 tablets of 10mg Percocet over a period of 72 hours immediately before the onset of her symptoms. Of note she had narcan in the ED without any improvement observed in her mental status.

ROS: As far as the family is aware, Mrs. X’s review of systems is negative for recent chills, chest pain, shortness of breath, nausea, vomiting, constipation, lymphadenopathy, dysuria, lower extremity edema, focal weakness, focal numbness, visual changes, headache, or rashes.

PAST MEDICAL HISTORY: Upper and lower dentures; migraines; degenerative disk disease; chronic back pain; hypothyroidism; hyperlipidemia; C-section x 2; uterine cancer, status post hysterectomy; appendectomy; carpal tunnel syndrome.

CURRENT MEDICATIONS

1. Acetaminophen 500 mg 2 tablets q. 4 to 6 hours PRN
2. Amitriptyline 100 mg 1.5 tablets at bedtime.
3. Carbamazepine 200 mg twice daily.
4. Diphenhydramine 25 mg twice daily as needed.
5. Estradiol 1 mg daily.
6. Gabapentin 600 mg 3 times daily.
7. Hydroxycut (unclear exactly how much patient is taking).
8. Levothyroxine 150 mcg daily.
9. Lipitor 80 mg daily.
10. Percocet 10/325 1 tablet every 4 hours PRN
11. Tramadol 50 mg twice daily as needed.
12. Tylenol Extra Strength 25/500 bedtime PRN

DRUG ALLERGIES: ASPIRIN, SULFA, FLAGYL, IBUPROFEN, MORPHINE, AMBIEN, IODINE DYE.

SOCIAL HISTORY: Ms X is married and is accompanied by her husband and daughter. She smokes 1 pack per day for the last 25 years. There is no ETOH or recreational drug use. She works in retail.

FAMILY HISTORY: Father with history of lung cancer, died of heart attack at age 70. Mother’s medical history is unknown.

PHYSICAL:

General: Adult female. Follows commands very poorly. Says almost no words, appears confused, but not in distress.

Vital Signs: Temperature 39.8, heart rate 97, respirations 22, blood pressure 135/55, O2 saturation 96% room air.

HEENT: Eyes: Conjunctivae noninjected, extraocular movements intact. Pupils reactive to light. Sclerae are anicteric. Oropharynx: Somewhat dry mucous membranes. Upper dentures are in place. No erythema or exudate. The patient will absolutely not permit posterior oropharyngeal examination.

Neck: Supple to full flexion. Nontender. No lymphadenopathy, JVD, thyromegaly, or carotid bruits appreciated.

Chest: Somewhat coarse bilaterally with good inspiratory effort, only fair cooperation on examination.

Back: No focal spinal tenderness. No costovertebral angle tenderness.

Cardiac: S1, S2, no murmurs, rubs, gallops appreciated. No heaves or lifts palpated.

Abdomen: Positive bowel sounds, soft, nontender, nondistended, no organomegaly or masses noted.

Extremities: No cyanosis, clubbing, or edema. No cervical or axillary adenopathy.

Neurologic: Altered level of consciousness as noted above. Grip strength is 5/5 bilaterally. Dorsi and plantar flexion appear to be 5/5 bilaterally, although patient has difficulty cooperating with this portion of examination. Cranial nerve VII intact. Pupils are symmetric and reactive to light. Plantar reflex down going. There is no clonus.

STUDIES:

WBC 9.3, hemoglobin 13 g/dL, platelets 320,000 with 84% neutrophils.

Sodium 134 mEq/L, potassium 3.3 mEq/L, calcium 8.5 mg/dL, CO2 29 mEq/L , BUN 14 mg/dL, creatinine 0.8 mg/dL, glucose 116 mg/dL, Bilirubin 0.4 mg/dL, alkaline phosphatase 219 IU/L, ALT 30 IU/L, AST 47 IU/L, Albumin 4.0 g/dL, INR 1.0.

EKG: Normal sinus rhythm at 96.

Lactic acid 1.4 mg/dL

Carbamazepine level less than 2.

Urinalysis with specific gravity 1.027, leukocyte esterase negative, nitrite

negative, 4 white cells, 2+ bacteria.

Chest x-ray: left and right-sided infiltrate.

Assessment/Plan

A 56-year-old Caucasian female with a past medical history notable for chronic pain and polypharmacy. She now presents with 3 days of initial flu-like symptoms followed by confusion, generalized weakness, and diarrhea. She is admitted with the following:

1. Polypharmacy: Probable combination of excessive narcotic use and withdrawal since she has not had any medications for the last 3-4 days. Notably, she has been prescribed Benadryl, gabapentin, Percocet, tramadol. For now, we will continue her medications and hold for diminished level of consciousness.
2. Pneumonia: Left and right-sided infiltrates are noted on chest x-ray. As she was feeling like she might have the flu initially when she was still verbal, we will prescribe Tamiflu. We will prescribe Rocephin and Zithromax for potential community-acquired pneumonia. Also, we will prescribe vancomycin as there is a potential for MRSA pneumonia associated with influenza. Given the duration of symptoms, I believe that Tamiflu will likely not be very effective. We will check influenza DFA.
3. Tobacco abuse: Order tobacco cessation protocol.
4. Diarrhea: unknown etiology, possibly related to influenza. Send stool for O&P, C-diff, & culture.
5. Weight loss: Patient with an intentional 25-pound weight loss in the past 2 months. She was taking Hydroxycut. However, given her propensity to overuse medications and the fact that she is on L-thyroxine, we will check a TSH in case she was overusing this.
6. Confusion: I hope that the confusion is explained by the above. If it does not improve, further workup could be considered including imaging, etc. Of note, there was absolutely no meningismus in the emergency department on examination.

Mrs. X was admitted to your service overnight and the above H&P is reflective of the work completed by the overnight physician approximately 10 hours ago. You read the H&P and go re-evaluate Mrs. X. Her condition has remained unchanged from admission. She continues to be febrile with a temp of 38.5 and other vitals are normal. On examination she continues to be minimally responsive. She is able to follow some commands with great difficulty. She looks at you when you speak but does not hold the gaze long. She has no dyspnea and is maintaining her sats at 95-97% on room air. Abdominal assessment is negative. Face is symmetrical, PERL. Movements of her extremities are equal. TSH is normal. She has had the first doses of her antibiotics.

Questions:

1. Based on the current available data, what differential differential diagnoses can you rule out as a cause of the altered mental status? Give a rationale as to why you are able to rule out each potential diagnosis.
2. Based on the available clinical data, what differentials still need to be rule out?
3. What additional diagnostic tests should be ordered to further evaluate the altered mental status? What additional historical information do you want to collect from the family?
4. Write  an updated assessment and treatment plan for each of the problems identified in the H&P above. You must address all of the problems above and have a complete treatment plan for each problem (except for weight loss). All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated.
5. What is the most appropriate level of care for this patient?
6. What physician specialty or other interprofessional consults should be ordered?
7. What anticipatory guidance/patient education should you provide the husband?

Answer 1

Differential diagnosis

1. Electrolyte imbalance

2. Drug overdose

3. Acidosis or alkalosis

Additional diagnostic tests

1. ECG stat

2. Blood culture

3. ABG

CONSULTATION

1. Neurologist

2. Psychaitrist

3. Family councellor

Education

1. risk for injury

2. Consent for restraining

TREATMENT PLAN

Polypharmy : get psychiatric consultation and adjust narcotic drug dose accordingly

Pneumonia : get blood culture done and change antibiotic if needed.

Diarrhoea : fluid replacement and monitor intake output

confusion : watch for next 24 hours as she is getting regular medicines back and electrolytes are being replaced.