Identifying data:

Name: RD

Sex: Female

Address: Queens

Date of birth: 10/2/1946, 74 y/o 

Date & Time: 6/01/21, 9:20 am 

Location: Queens Hospital Center, IM

Marital status: Widowed 

Religion: Islamic

Race: Bengali

Source of information: daughter-in-law, reliable 

Mode of transport: EMS

Chief Complaint: Altered Mental Status  

HPI:

RD is a 74 y/o Bengali speaking female with a PMHx of Dementia, T2DM and Cirrhosis presents from home for altered mental status x1 day. History was obtained in person from the patient’s daughter-in law as the patient is obtunded.

As per the patient’s daughter-in-law, she called EMS as the patient appeared altered from her baseline which is alert and oriented with mild cognitive impairment secondary to dementia and verbally communicates in her native tongue, Bengali. Pt lives with her son and daughter-in-law, ambulates with a cane and walker and is dependent in ADLs and IADLs. DIL reported that patient was having bouts of anxiety attacks that were worse than episodes of anxiety patient had in the past and her behavior progressed to the point where she was getting combative and less re-directable. Upon asking if pt had been drinking more water lately, as patient was found to be hyponatremic, DIL stated they have been compliant with 1.5L/day of fluid and salt restriction as instructed by her hepatologist. No new medications were started but patient’s Lasix was increased from 20mg daily to 40mg daily and spironolactone was increased from 25mg daily to 50mg daily as her hepatologist noted “belly and feet swelling.” Patient has urinary frequency at baseline, is worse on diuretics, and was noted to have malodorous urine with more urinary frequency than while on increased diuretic treatment.

Daughter-in-law unable to express appreciable weight loss but expressed that “patient’s belly used to be big but not since diagnosis of cirrhosis a few months ago.” Patient has been having difficulty swallowing, dysphagia, x2-3 days, mostly to solids, can tolerate liquids. Patient has Last meal was last night where pt only had a small portion of rice and curry. She deferred specifics about weight change to PCP, Dr. Kahn.

DIL denies fever, cough, change in sleep, diarrhea, falls, recent trauma to the head, blood in urine, history of alcohol use or hx of hepatitis.

ED course:

ED initial vital signs –

• Temp: 97.8 F
• Pulse: 80
• RR: 16
• BP: 100/53
• SpO2: 100%

Imaging –

• CXR – no radiographic evidence of acute pulmonary abnormality.
• CT head without contrast – patchy areas of low attenuation, likely ischemic/hypertensive in nature. No acute hemorrhage, hydrocephalus or territorial infarcts. If sx’s persist or worsen, consider further evaluation.
• CT abdomen pelvis without contrast – no CT evidence of acute intra-abdominal process.

Between arrival to ED and admission to the floor, patient’s AMS gradually worsened and upon presentation to the floor patient was obtunded.

Past Medical History:

Present illnesses:

• Dementia – 2018
• T2DM – 2001
• Cirrhosis – DIL doesn’t know/remember

Immunizations: up to date (influenza, zoster, pneumococcal)

Past Surgical History, Family History, Allergies:

Follow up with PCP, Dr. Nazbul Kahn

Medications:

Atorvastatin 20mg nightly

Vitamin B12 500mg daily

Dulcolax 100mg daily

Donepezil 10mg nightly

Ferrous sulfate 325mg daily

Lasix 40mg daily

Glimepiride 2mg twice daily

Insulin 30 U nightly

Pioglitazone 15mg daily

Propranolol 20mg daily

Spironolactone 50mg daily

Ursodiol 300mg twice daily

Social History:

RD is a single female, lives with her son and daughter-in-law. Is ambulatory with a cane and walker and is dependent in her ADLs and IADLs.

Denies alcohol, tobacco, illicit drug use or sexual activity.

Diet – Appetite is usually normal, has had decreased appetite/oral intake for the past few days.

Patient sleeps well, typically 5 hours a night.

Exercise – doesn’t walk around much, daughter-in-law encourages her to walk around as much as possible

ROS:

Unable to do direct ROS as patient is obtunded.

Physical Exam:

General: 

74 y/o female is an obtunded, frail elderly lady. She is not in acute distress, not ill-appearing, toxic-appearing or diaphoretic.  

Vital Signs: 

BP: 98/50 

R: 18 breaths/min unlabored 

P: 82 beats/min, regular rhythm 

T: 98.6 degrees F (axillary)

O2 Sat: 100% Room Air

Weight: 107 lb

Skin, Hair, Nails and Head:

Skin: Warm & moist, poor turgor, smooth texture, non-icteric. No thickness, opacities noted. No lesions, masses, scars or tattoos noted. 

Hair: Average distribution and quantity. 

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, no deformities and specific faces noted, non-tender to palpation throughout.

Eyes:

Symmetrical OU, conjunctiva normal. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No strabismus, exophthalmos or ptosis. Sclera white, conjunctiva clear. 

Visual fields full OU. PERRL – pupils sluggishly responsive to light, EOMs intact with no nystagmus. 

Ears:

Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Auditory acuity intact to whispered voice AU. Weber midline/Rinne reveals AC>BC AU.

Nose: 

Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

Sinuses:

Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth: 

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions or deviation noted.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no palpable adenopathy noted.

Thyroid: 

Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Thorax & Lungs: 

Chest – symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation. 

Lungs – clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds. 

Abdomen: 

Abdomen flat, soft and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart:

Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Mental Status:

Patient is obtunded, unable to assess

Nervous System:

Patient is obtunded, unable to assess

Peripheral Vascular: 

Skin is normal in color, warm to touch, capillary refill <2 seconds. No calf tenderness bilaterally, equal in circumference. No palpable cords or varicose veins bilaterally. No cyanosis, clubbing or edema bilaterally. DP/PT pulses are 2+.

Musculoskeletal:

No tenderness, soft tissue swelling, ecchymosis, atrophy, crepitus in bilateral UE and LE. No evidence of spinal deformities. Cannot assess AROM or PROM as patient is obtunded.

Labs: 

CBC:

WBC – 8.04

RBC – 2.46 (l)

HGB – 11.7 (l)

HCT – 36.0 (l)

PLT – 143 (l)

MCV – 100.4 (h)

MCH – 34.1 (h)

MCHC – 34.0

MPV – 12.5

RDW – 15.7 (h)

BMP:

*Na – 125 (l)

K – 3.9

Cl – 92

CO2 – 23

*BUN – 27 (h)

*Cr – 1.47 (h)

*eGFR – 35 (l)

*Glu – 341 (h)

Ca – 10.1

LFTs:

ALT – 29

AST – 51

Alkphos – 193

Albumin – 3.0

Coags:

PT – 16.7

INR – 1.4

aPTT – 29.8

(Imaging – see ED note)

Differential diagnoses:

1. Urinary tract infection
   1. Altered mental status secondary to infection
   1. Malodorous urine with increased urinary frequency
   1. Elderly present atypically
2. Hepatic encephalopathy
   1. Hx of cirrhosis
   1. Neuropsychiatric sx present – AMS, obtundation, inappropriate behavior: combative, less re-directable, anxiety
   1. Hyponatremia – complication of advanced cirrhosis/HE
3. Behavioral disturbances secondary to worsening dementia
   1. Hx of dementia
   1. Potentially not controlled with medication
4. Urosepsis
   1. Obtunded
   1. Hypotensive
   1. Possible UTI
   1. Not likely – no fever, normal HR, normal RR
5. Hyperglycemia
   1. Uncontrolled diabetes, outside source A1c is 11.1
   1. glucose is elevated to 341

Assessment/Plan:

RD is a 74 y/o Bengali speaking female with a PMHx of Dementia, T2DM and Cirrhosis presents from home for altered mental status x1 day

Altered Mental Status – toxic metabolic encephalopathy secondary to UTI vs hepatic encephalopathy vs dementia with behavioral disturbances

• UTI
  • No elevated WBC count
  • Obtain UA, U-culture
    • UA results:
      • pH urine – 7.5
      • color urine – yellow
      • appearance urine – clear
      • specific gravity – 1.008
      • glucose – 100
      • nitrites – positive
      • leukocyte esterase – moderate
      • WBC – 21-50
      • Bacteria – moderate
      • Squamous epithelial cells – 5-6
      • Bilirubin, ketones, blood, protein, RBC, hyaline casts – negative
  • Once urine studies obtained à 
    • Zosyn, vancomycin and ceftriaxone x1 dose
• Hepatic encephalopathy
  • Obtain Ammonia levels
    • Normal range 11-51. Initial result = 269, post-lactulose result = 22
  • Monitor BMs – if ammonia is elevated à start lactulose with goal of 2-3 BM/day
  • c/w fluid restriction
  • monitor BMP for sodium
  • hold Lasix, spironolactone and propranolol for now. Resume slowly as BP tolerates

Uncontrolled T2DM

• outside records = HA1c: 11.1 (5/25/2021)
• hold home Levemir while patient is NPO
• monitor FS twice daily for now, change as PO intake changes
• change medication

AKI vs CKD

• outside records = Cr: 1.28, GFR: 41 (5/15/2021)
• follow BMP

Cirrhosis

• follow with Hepatologist at Weil Cornell
• try to obtain collateral information from PMD
• follow LFTs

Dementia

• continue with donepezil 10mg x nightly

DVT prophylaxis pantoprazole 40mg IV