Presented by Devon Moore, MD
She does not voice a specific chief complaint. She was brought in as a medical code to ED by ambulance from home for “not acting herself”
This is a 59-year-old woman brought into the emergency department as a medical code from home by ambulance. According to family members, the patient appeared to be confused. She does not seem to be acting herself, and she is very unsteady on her feet. This occurred within the past couple of hours. The patient is conscious but does not seem to be responding appropriately to family members. On arrival the patient is alert and oriented to person. She is able to answer simple questions and follow simple commands. She denies any complaints of a headache at this time. No chest pain, difficulty in breathing, abdominal pain, nausea or vomiting. She denies any extremity-related complaints. She has had no recent illnesses.
Past Medical, Family, and Social History:
PCP: The patient does not have a primary care physician.
PMH: HTN. It is negative for diabetes, known CAD or stroke.
Meds: She is not currently on any medications.
FH: HTN, and negative for diabetes or CAD.
SOCIAL: She lives with her daughter. She does not smoke tobacco; consume alcohol or use illicit or I.V. drugs.
Vitals: BP was 225/130, HR was 94 and regular, and RR was 18. Temperature was 36.5. 99% RA
General: She was conscious. She was alert, but her speech was difficult to understand. It appears that she may have had either an expressive aphasia, or possibly some mild dysarthria. She was trying to tell me her name, but it was not understandable. When asked to take a deep breath, she would open her mouth wide as if to take a deep breath, but she would not breathe deeply. She did this repeatedly. HEENT: On exam, there was no trauma or abnormality of her scalp. The pupils were about 4mm, round and reactive to light. EOM were intact; however, she had some element of a nystagmus (not clearly horizontal or vertical). It may be rotary. Her fundi looked to have a slight indistinctness of her left fundus and optic disc. There was no obvious hemorrhage. Her right optic disc was sharp without any obvious hemorrhage. Her mouth was without intraoral lesions, and she had a positive gag reflex. Her neck was supple with no nuchal rigidity. No meningismus. Trachea was midline without deviation. Carotids were 2+ and without bruits. No JVD.
RESPIRATORY: CTA bilaterally, with no rales or wheezes. She was not cyanotic or diaphoretic. No accessory muscle use.
CARDIAC: normal S1 and S2. No S3 or S4 gallops. No murmurs or rubs. Good distal pulses. Chest wall was non-tender.
MUSCULOSKELETAL: good pulses, no acutely inflamed joints. Symmetric muscular strength and tone, and is able to move her extremities distally.
NEUROLOGIC: awake, alert and oriented to person. No obvious sensory deficits to soft touch. Deep tendon reflexes were hyper-reflexic. Patella and Achilles were 3+. She had clonus of both lower extremities and a slightly up-going toe on the left. She had a downward plantar response on the right. She had dysmetria seen with the left hand (right not tested). Gait not tested, but when transferring her from EMS bed to resuscitation bed, she was uncoordinated and constantly fell on her left side while trying to “scoot” to the left to the next bed.
• Accu-check was 192
• 12-lead-EKG showed normal sinus rhythm at 87 bpm, normal axis, no ventricular ectopy, normal PR, QRS, and QT intervals. A voltage criterion for LVH is met.
• Single-view CXR did not show any evidence of infiltrate, pneumothorax, or effusion. There was no significant cardiomegaly.
1. Which of the following would be the next most appropriate steps to take to make a diagnosis?
a.) CBC, lytes, BUN, cr, U/A, UDS and SDS
b.) Aortic angiography
d.) CT Head
e.) Plasma metanephrine testing, MRI abdomen
2. Which is the most appropriate in management of this patients’ blood pressure?
a.) I.V. vasodilators and/or adrenergic antagonists for rapid reduction in BP to obtain a normal level (<140/90)
b.) Maintain SBP <160 mm Hg, and give oral nimodipine
c.) Reduce mean arterial pressure (MAP) up to 20-25% over the first hour of treatment, use short acting and titratable agents I.V., with constant patient monitoring
d.) I.V. Alpha-adrenergic antagonist therapy only to reduce BP
e.) SBP <160, DBP <110, and I.V. magnesium sulfate
3.) Which of the following is most closely associated with the term ‘hypertensive emergency’?
a.) SBP >200, DBP >120
b.) SBP >200, DBP >120 with pre-existing conditions (CHF, CAD, Renal insufficiency)
c.) acute end-organ damage
d.) longstanding, poorly controlled HTN
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