Student Case #4

[deborah212]

Bread and butter reason for admission in hospitalist medicine:

 

75 yo female brought in by granddaughter due to altered mental status

 

Vitals T 99.2 P 90 BP 118/68 RR 20 O2 Sat 99% on RA

 

What do you want to know?

[rev ronin]

PMH: Any DM, HTN, CAD, AMI?

 

Last time seen normal?

Altered can mean a lot of things--what is the granddaughter's specific observation?

 

Initial labs: finger stick glucose, Urine dip.

 

Initial DDx: CVA, Cardiac, UTI, Hypoglycemia.

[SCHMITTIE120]

i think revs got most of it, I am thinking UTI

[deborah212]

PMH: Any DM, HTN, CAD, AMI?

HTN

GERD

mild dementia

 

Last time seen normal?

"My grandmother was back to her usual self yesterday but when I woke up this morning, she was walking around the house aimlessly."

 

Initial labs: finger stick glucose, Urine dip.

Fingerstick 87

UA: Cloudy. pH 5.2, specific gravity 1.029. 3+ leukocyte esterase, negative nitrite, trace protein, trace blood, no ketones or glucose

 

i think revs got most of it, I am thinking UTI

As usual, history is going to be very important in this patient (hint, hint). Let's do a little back tracking before we get to labs/any imaging.

[kbtennis]

In addition to rev...what's her orthostatic BP, what drugs is she on, has she experienced any falls or head injuries, any comorbid conditions?

[ohiovolffemtp]

Top 3 in my mind: hypoglycemia - even though 87 what is her normal, UTI, medication issue - check pupils.

 

Do a 12 lead to rule out cardiac. Given the HTN hx, consider stroke/TIA - check for side-to-side differences.

[deborah212]

In addition to rev...what's her orthostatic BP?

Do a 12 lead to rule out cardiac. Given the HTN hx, consider stroke/TIA - check for side-to-side differences.

Let's get the history before physical exam.

 

has she experienced any falls or head injuries

No falls or recent head injuries.

 

what drugs is she on

Atenolol 25 mg qd

Enalapril 10 mg qd

Omeprazole 40 mg qd

Ciprofloxacin 500 mg BID

 

So where are we with the HPI and rest of the history?

[rev ronin]

So... why is she taking Cipro?

 

Social/family hx?

Hx of UTIs?

 

She appears dehydrated: SG is too high, hr is a bit high, and BP is possibly low for what I'd expect for a 2-drug HTN regimen. Let's confirm via PE and get some fluids into her while we keep talking to her...

[Just Steve]

Recent outside changes to her normal daily activities? By outside changes, I mean re location, vacation, new visitors, change of care facilities...things that happen to her, not "in" her. Previous etoh/tobacco/drug use? Previous surgeries, illnesses that required medical intervention such as cancers/tumors? Recent appetite/oral intake amount normal or abnormal?

[Guest guthriesm]

Any other associated symptoms? What has her appetite been like? Any recent infections? Any complaints of abdominal pain, urination problems, chest pain, etc?

[sailordeac]

"My grandmother was back to her usual self yesterday but when I woke up this morning, she was walking around the house aimlessly."

 

Can this be clarified, or am I reading too much into it? It sounds from this statement like she had altered mental status, was better yesterday, then worse today. If so, when did all this start, and was she doing anything else besides "walking aimlessly" that indicated to the granddaughter that her mental status was altered? Has she had anything like this before?

[chiaroscuro27]

Wow...we skipped over the history part of "taking a history." I have a few questions:

 

When did the AMS begin and in what setting (i.e what was the grandmother doing at the time of onset), and has it happened before?

Has the AMS been consistent or intermittent. How long has it lasted...hours, minutes?

Is the AMS associated with any nausea, vomiting, diarrhea, blurred vision, lightheadedness, HA, abdominal pain?

Has the pt or granddaughter tried anything to alleviate the AMS and any other sx, and if so have they worked?

 

Next, any allergies? She is on BP meds and PPI's. Has she been taking them as prescribed. Has she been taking more that what's prescribed? Any history of illicit drug use/ETOH abuse? I'm curious what a "normal" BP reading is for her.

 

The leukocyte esterase is high, which suggests UTI. Is she on the Cipro for that? How long has she been taking it? Does she suffer from chronic UTI's? If so, when was the last one and what was it treated with?

 

FH: any hx that she could provide, but I would ask about hx of CVA/TIA, CAD, liver disease.

 

Any recent upper respiratory infections, lumps or bumps noticed in the neck, blood noticed in the stool/urine, coughing/vomiting blood, abdominal pain/distention, urinary frequency/urgency/pain, loss of consciousness, blurred vision.

 

That's all I got for now.

[rcdavis]

Wow...we skipped over the history part of "taking a history." I have a few questions:

 

When did the AMS begin and in what setting (i.e what was the grandmother doing at the time of onset), and has it happened before?

Has the AMS been consistent or intermittent. How long has it lasted...hours, minutes?

Is the AMS associated with any nausea, vomiting, diarrhea, blurred vision, lightheadedness, HA, abdominal pain?

Has the pt or granddaughter tried anything to alleviate the AMS and any other sx, and if so have they worked?

 

Next, any allergies? She is on BP meds and PPI's. Has she been taking them as prescribed. Has she been taking more that what's prescribed? Any history of illicit drug use/ETOH abuse? I'm curious what a "normal" BP reading is for her.

 

The leukocyte esterase is high, which suggests UTI. Is she on the Cipro for that? How long has she been taking it? Does she suffer from chronic UTI's? If so, when was the last one and what was it treated with?

 

FH: any hx that she could provide, but I would ask about hx of CVA/TIA, CAD, liver disease.

 

Any recent upper respiratory infections, lumps or bumps noticed in the neck, blood noticed in the stool/urine, coughing/vomiting blood, abdominal pain/distention, urinary frequency/urgency/pain, loss of consciousness, blurred vision.

 

That's all I got for now.

 

Finally. Starting to approach this patient to where the answer is.

[chiaroscuro27]

Oh, rcdavis, you don't know how good it feels to hear YOU say that! If my preliminary history taking gets your stamp of approval, I'm golden!!!!

[rev ronin]

With all due respect, the history->exam->labs/imaging order as a general order may be just fine, but is not appropriate for the patient as presented here.

 

If this patient is altered, I need to rule out all the things that might just kill her while we sit around trying to exact a history from a third party who may or may not have useful information. If glucose, ECG, etc. have all been ruled out in the ED as causes for the altered mental status before the patient is admitted, super! That would be great information to have in the chart, but if it's not there, I'm absolutely going to get it first.

 

I realize there's a tension here between getting us to think through things step-by-step and giving us too much information such that there is no actual challenge. Still, if I don't have a glucose on an altered patient, I'm ordering (or doing) one now, and we can talk history when it turns out to be non-contributory.

[deborah212]

With all due respect, the history->exam->labs/imaging order as a general order may be just fine, but is not appropriate for the patient as presented here.

I realize there's a tension here between getting us to think through things step-by-step and giving us too much information such that there is no actual challenge. Still, if I don't have a glucose on an altered patient, I'm ordering (or doing) one now, and we can talk history when it turns out to be non-contributory.

When I choose cases for the student forum, they are meant to be appropriate for discussion, especially in the practice of thinking systematically about patients and the differential diagnosis. I specifically do not choose the septic hypotensive pneumonia patients or the acute hemorrhagic CVA as real time management cannot be discussed appropriately in this platform. You have great ideas but would encourage you to go the full history "long route" with these discussions as I choose these cases very carefully. They are usually the ones where I have learned something too.

 

"My grandmother was back to her usual self yesterday but when I woke up this morning, she was walking around the house aimlessly." Can this be clarified, or am I reading too much into it? It sounds from this statement like she had altered mental status, was better yesterday, then worse today. If so, when did all this start, and was she doing anything else besides "walking aimlessly" that indicated to the granddaughter that her mental status was altered? Has she had anything like this before?

At baseline, the grandmother knows her surroundings and recognizes family members and is quite active in local bingo though needs some help with her IADLs (bill paying and house cleaning) due to some mild dementia. However, 7 days prior to admission, the granddaughter noted some urinary incontinence, and most notably, the patient forgetting her weekly bingo meeting. At her PCP urgent care visit, patient was afebrile with normal BP and HR, oriented x 3, but had a positive UA in the setting of dysuria and incontinence so was begun on empiric treatment with cipro for a 7 day course (last 2 doses on day of admission). After several days of antibiotics, urinary symptoms resolved and patient resumed normal activities. Urine culture sent by PCP was found to be pansensitive E. coli so no changes were made to antibiotics.

 

Hx of UTIs?

Has the pt or granddaughter tried anything to alleviate the AMS and any other sx, and if so have they worked?

No. Granddaughter does note that patient becomes more forgetful when she has infections similar to when she has pneumonia 2 years ago.

 

Has the AMS been consistent or intermittent. How long has it lasted...hours, minutes?

The granddaughter brought the patient straight to the ED given the last time the patient acted like this "she had to be hospitalized for several days due to pneumonia" aforementioned above. Describes this morning events as confusion- patient was half-dressed and was pacing back and forth from the kitchen to the living room. Through she recognized her family members, could not explain her activity. However, since arrival to emergency room granddaughter feels she's back to her baseline and that maybe she overreacted.

 

Is the AMS associated with any nausea, vomiting, diarrhea, blurred vision, lightheadedness, HA, abdominal pain?

Any other associated symptoms? What has her appetite been like? Any recent infections? Any complaints of abdominal pain, urination problems, chest pain, etc?

No to all of the above except for appetite. Some anorexia early on for UTI but appetite has returned with good po yesterday though only a bit of juice today.

 

Next, any allergies? She is on BP meds and PPI's.

I'm curious what a "normal" BP reading is for her.

No allergies. Granddaughter lays pills out daily and monitors compliance. All medications have been prescribed by PCP. Normal BP per EMR is 120s-130s. Patient has taken anti-hypertensives already this morning. As an aside, this is an essential question to ask when admitting and writing orders for a patient.

 

Previous surgeries

s/p open chole ~20 years ago

 

FH: any hx that she could provide, but I would ask about hx of CVA/TIA, CAD, liver disease.

Father with HTN but no other notable family history. No known vasculopathic FMHx.

 

Social/family hx?

Previous etoh/tobacco/drug use?

Retired secretary from a large law firm. Lives with granddaughter in a small house where she has some assistance as described above. Quite active with local senior organizations. Former smoker with 10 pack years. Quit 30 years ago. No EtOH or drugs other than prescribed.

[deborah212]

Vitals on Admission:

T 99.0 P 89 BP 116/70 RR 20 O2 Sat 100% on RA. Orthostatics negative.

Gen- Elderly female sitting quietly on stretcher. NAD.

HEENT- PERRL. EOMI. Mucous membranes slightly dry. OP clear without erythema.

Neck- No LAD. JVP at 6 cm.

CV- S1 + S2 RRR II/VI holosystolic murmur at apex

Pulm- CTAB

Abd- +BS Soft, no tenderness in any quadrant. No CVA tenderness

Ext- No edema. Calves nontender.

Neuro- Alert. Oriented to person and place (hospital) but not to time or president. CNII-XII grossly intact. Good grip strength. 5/5 symmetric strength against resistance of upper and lower extremities bilaterally. 1+ patellar reflex with downgoing toes. Unable to ellict upper extremity reflexes. Negative pronator drift. Gait not tested thought nursing reports ambulated well to bathroom prior.

 

Anything changed in your differential? Any other questions you'd like to ask? We already have a UA... what else would you like to see?

[marilynpac]

Has a TSH been done???

[rev ronin]

When I choose cases for the student forum, they are meant to be appropriate for discussion, especially in the practice of thinking systematically about patients and the differential diagnosis. I specifically do not choose the septic hypotensive pneumonia patients or the acute hemorrhagic CVA as real time management cannot be discussed appropriately in this platform. You have great ideas but would encourage you to go the full history "long route" with these discussions as I choose these cases very carefully. They are usually the ones where I have learned something too.

 

That's a helpful clarification, thanks.

 

At this point, I'm concerned about a non-UTI infection, or maybe she's developed a secondary UTI of a cipro-resistant organism, less concerned about possible CVA, Cardiac, or Glucose issues, and still think she looks dehydrated.

 

At this point I'm thinking infectious (run another urine culture?) or endocrine (TSH = good idea).

[bradtPA]

Altered mental status, incontinence. Those two facts should make you include what brain problem in your differential?

[chiaroscuro27]

I have another question.

 

What has her urine output looked like over the past few days? No CVA tenderness, but perhaps something is going on with the kidneys that may be tied to the murmur. Sounds like Mitral Regurg. I was considering a bleed of some sort earlier, but the history and PE findings don't fit.

 

I'd like to get a few values: CBC with diff, and most important to me a Chem 7. I'm particularly interested in the BUN level.

 

My Ddx:

 

Uremia

Urosepsis (not likely, doesn't fit the history)

Mitral Regurgitation

 

Not long enough for my taste, but I can't think of anything else right now.

[chiaroscuro27]

Brad, are you referring to hydrocephalus?

[cobramarty]

I had to re-read from the start. No one asked is she SOB, cough, DOE, pain on breathing, can't take a deep breath. Abnormal VS T99.2 RR20. Dry mouth- mild dehydration and lungs clear- could be a lung process with no abn lung sounds due to dehydration. Daughter telling you pneumonia in past. Cipro not great choice for CAB/CAP.

[deborah212]

Here we go... I'm only going to give you the data you specifically ask for because there are several key features that will clinch the diagnosis.

 

At this point I'm thinking infectious (run another urine culture?) or endocrine (TSH = good idea).

TSH- 0.55

Urine Culture- sent and pending (takes 24 hrs for colonies and another 24 for speciation/sensitivities).

 

Altered mental status, incontinence. Those two facts should make you include what brain problem in your differential?

Head CT was ordered by the ED and was negative. For the students, it's always good to keep an open mind. I was working up a progressive dementia patient several weeks ago so sent off the usual RPR, TSH, B12, Folate and did end up diagnosing her with pernicious anemia (had a slightly macrocytic anemia and was positive for intrinsic factor antibody). This patient did not have any other stigmata other than cognitive decline.

 

No one asked is she SOB, cough, DOE, pain on breathing, can't take a deep breath. Abnormal VS T99.2 RR20. Dry mouth- mild dehydration and lungs clear- could be a lung process with no abn lung sounds due to dehydration. Daughter telling you pneumonia in past.

No dyspnea or cough. ED did give a liter a fluid before labs sent.

 

What has her urine output looked like over the past few days? I'd like to get a few values: CBC with diff, and most important to me a Chem 7. I'm particularly interested in the BUN level.

Fabulous.

 

WBC 10.2 > 12 / 36 < 250 Diff: Neutrophils 70%, Lymp 21%, Mono 4%, Eos: 5%,

Na 134, K 3.3, Cl 108, CO2 18, BUN 26, Cr 2.62, Glucose 85

Baseline Cr per EMR is 0.9

 

Granddaughter reports urinary incontinence/dysuria resolved with cipro. Has not noticed a decrease in UO over the past several days but is unsure.

 

What do you guys think about those labs? What else should we be looking at?

[rev ronin]

Mild hypokalemia and hyponatrmia, but the AKI is what jumps out at me. Other Chem 7 values look normal. The question now is... what caused the AKI? Prerenal and ATN are the most common causes, but the ratio would favor infrarenal cause. Can we get an FeNA and FeUrea?