Emergency Medicine by James Gary

Author:James Gary [Gary, James]
Language: eng
Format: azw3, mobi, epub
Publisher: UNKNOWN
Published: 2021-07-27T16:00:00+00:00

Altered Mental Status

Answers

247. The answer is c. (Rosen, pp 1748-1750.) The patient never received a fingerstick glucose at triage. Hypoglycemia can mimic a cerebrovascular accident or seizure. Therefore, it is critical that all patients who present with altered mental status get fingerstick glucose. Glucose level should be considered a vital sign. Hypoglycemia is a common problem in patients with type 1 diabetes. The clinical presentation of hypoglycemia is caused by increased secretion of epinephrine, as well as central nervous system (CNS) dysfunction. Symptoms include diaphoresis, nervousness, tremor, tachycardia, hunger, and neurologic symptoms ranging from confusion and bizarre behavior to seizures and coma.

(a) Ethanol withdrawal can present in a similar fashion as hypoglycemia since both include symptoms of an adrenergic state (eg, tachycardia, hypertension, diaphoresis, agitation). Even if you suspect ethanol withdrawal, it is mandatory to check fingerstick glucose. (b) The stroke team should be activated in patients who present with signs and symptoms of a stroke that are not caused by hypoglycemia. Therefore, these patients need a fingerstick glucose. (d) Sundowning refers to people who become increasingly confused at the end of the day and into the night. Sundowning isn’t a disease, but a symptom that often occurs in people with dementia, such as Alzheimer disease. It is more commonly observed on the hospital wards than in the ED. (e) Haloperidol is commonly used as a sedative for agitated patients. However, this patient is agitated because of an organic cause, hypoglycemia. By treating the underlying cause (administering glucose), the agitation will resolve.

248. The answer is d. (Tintinalli, p 1314.) Myxedema coma is a lifethreatening complication of hypothyroidism. Mortality in myxedema coma approaches 20% to 50% even with appropriate management. The patient exhibits classic signs and symptoms of the disease: lethargy or coma, hypothermia, bradycardia, periorbital and nonpitting edema, and a delayed relaxation phase of deep tendon reflexes (areflexia in more severe cases). Myxedema coma can be triggered by sepsis, trauma, surgery, congestive heart failure, prolonged cold exposure, or use of sedatives or narcotics (as seen in this example).

280 (a) It is critical that fingerstick glucose is checked. However, myxedema coma differs from the early stages of hypoglycemia in that myxedema coma results in the progressive slowing of all bodily functions; by contrast, in early hypoglycemia, the body is stimulated by the release of adrenergic hormones. (b) The classic findings in opioid toxicity include miotic pupils and respiratory depression. (c) Stroke should be on the differential in this case, but the patient’s signs and symptoms are more consistent with an abnormal metabolic state than with purely neurovascular change. Depression (e) is an often forgotten diagnosis in the elderly and may present with a wide variety of signs and symptoms. Severe depression may appear as lethargy. It is unlikely, however, to have associated hypothermia and abnormal reflexes.

249. The answer is e. (Roberts and Hedges, pp 19-24.) Patients frequently present to the ED with agitation. It is important to discern what is causing their agitation; the range of etiologies is expansive, from ethanol intoxication to intracerebral bleeding.

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.