Case Study – Altered Mental Status

It’s about mid-afternoon on a warm fall day. You’ve been pretty steady throughout the day, but eventful. You were just about to try and catch a power nap when the vocal alarm opens up… “respond to a twenty six alpha one, sick person…”

The collective sigh between you and your EMT partner are audible. As you take your time for a low priority call, you begin to think of the situation. As you scroll through the history for this address, you begin to notice they call a lot. “I recognize this address” you state to your partner.

“Yeah, we’ve been here once or twice in the past month for the older one.”

You spot two older men flagging you down as they discuss among themselves what they each think is going on.

“We found her about 3 am in the bathroom acting very strangely, so we picked her up and put her in her bed. When we checked back later she was still acting the same way but not responding to any of our questions.”

“How old is she?” you query.

“She’s 54,” they after some discussion.

You quickly gather a medical history, well, what you can get. The family is extremely poor historians and your history is a best guess based on medicine bottles. The patient seems to be very lethargic and confused, follows direction poorly, and doesn’t answer questions that require a complex response. Her face is symmetrical and speech is clear. She is able to follow the simple commands to complete the pre-hospital stroke screen.

You gather she is a diabetic on a sliding scale of insulin, has a history of hypertension and what her family describes as “mini-strokes.” She also smokes heavily as evidenced by the smell and massive amounts of cigarette butts in a ashtrays around the house. The patient is able to answer to yes to questions about vomiting and headaches. You quickly check her pulse rate to find it at about 120, her respiratory rate at 18 and unlabored, and her initial capillary blood sugar is 123.

You are unable to get the cot any closer to the patient, so the decision is made to try and ambulate her to the cot. She does so with an unsteady gait and requires some assistance. She attempts to sit in another chair when you direct her to the cot, but she pleads “need to sit, need to sit,” so you and your partner usher her to the cot and get her secured. You lift her up and get her into the back of the ambulance.

She tries to get off the cot, but you smoothly keep her on it while you attach electrodes and the rest of the diagnostic monitoring equipment. The monitor shows a sinus tachycardia at 118, blood pressure is 186/112, and pulse oximetry shows her at 94% on room air. You easily establish IV access in the forearm with an 18 gauge and signal your partner you are ready to go. On the way to the hospital, the patient vomits several times and doesn’t follow your instructions on the use of a vomit bag. “Such is life…” you grumble as this will mean you will have a pretty lengthy clean up afterwards. She continues to vomit as you arrive at the ED.

You roll the patient back to bed and give a brief report to the very busy ED nurse.

Here’s the “Which Way Batman” part of the story. What’s your diagnosis?

  • Primary concerns are SAH, thyroid emergency, and OD. I would have gone ahead with an antiemetic just incase she is no longer able to maintain her airway. Safe and expeditious transport.

  • Primary concerns are SAH, thyroid emergency, and OD. I would have gone ahead with an antiemetic just incase she is no longer able to maintain her airway. Safe and expeditious transport.

  • I don’t know that I would give an antiemetic if OD is a possible cause of the problem, could this have been a medication error/reaction? My better half and I wonder about a possible bowel obstruction/peritonitis? Did the pt feel feverish? Color, Abdomen?

    • Anonymous

      I think zofran would work well in this case, effects without the side effects. I wish we had it, I guess one of those things in the works. She hasn’t had any medication changes in a while per the family, but they are poor historians. She was warm and dry, pink and abdomen non-tender.

      • Mark Zanghetti

        no Zofran here either, but OK. Any signs of dehydration? Alcohol consumption? LOI? Any odors?

        • Mark Zanghetti

          When I asked about odors, i meant from the pt and not the ashtrays, what did the vomit look like?

          • Anonymous

            Watery brownish. No alcohol. Dehydration is a thought, but unlikely.

            I’m leaning less physiologic and more neurologic

          • Mark Zanghetti

            12 lead? Any Hx of inner ear?

  • I don’t know that I would give an antiemetic if OD is a possible cause of the problem, could this have been a medication error/reaction? My better half and I wonder about a possible bowel obstruction/peritonitis? Did the pt feel feverish? Color, Abdomen?

    • I think zofran would work well in this case, effects without the side effects. I wish we had it, I guess one of those things in the works. She hasn’t had any medication changes in a while per the family, but they are poor historians. She was warm and dry, pink and abdomen non-tender.

      • Mark Zanghetti

        no Zofran here either, but OK. Any signs of dehydration? Alcohol consumption? LOI? Any odors?

        • Mark Zanghetti

          When I asked about odors, i meant from the pt and not the ashtrays, what did the vomit look like?

          • Watery brownish. No alcohol. Dehydration is a thought, but unlikely.

            I’m leaning less physiologic and more neurologic

          • Mark Zanghetti

            12 lead? Any Hx of inner ear?

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