Monday, October 09, 2006

Change in mental status

45 year old man, presented with a persistant cough that did not go away despite 4 different antibiotic course, some kenalog, some anti-allergy meds, and finally a CXR that showed "Right middle lobe pneumonia"

He was admitted for the persistent cough.
ROS no weight loss, SOB, nightsweats. Just the cough (non productive).
SOCIAL HISTORY: married,self-employed painter. He smokes cigars usually five times a week. He averages six to 12 alcohol beverages per week.

On exam the next day he was alert but confused. His vitals were normal as was his saturation on room air. He did not answer questions. He just looked at his wife and smiled. A Na was 129 when before on admission it was 137. The rest of the labs were unremarkable. LP, EEG and head CT were done but negative. By the trime some of that came back he was already becoming more oriented on his own. The next day he was a/o x 3.
Any feedback before I proceed?

5 comments - CLICK HERE to read & add your own!:

Anonymous said...


Anonymous said...

Is that a pseudo-tumor on the R on the lateral view?

Anonymous said...

Confused in what way? Any s/s of autonomic instability to suggest alcohol withdrawl/DT's? Was his blood suger normal during the confused episode, are is he diabetic and the low glucose is pseudohyponatremia...

If this was Legionella, one of the four previous antibiotic courses should have treated it. Hard to pin this on a bacterial infection, although any viral encephalitis could cause waxing and waning mental status. Doesn't explain the cough, though.

Did you consider Blasto?

Jennings said...

glucose normal. ABG normal. Confusion was that he did established eye contact but did not respond to questions. He followed simple commands but was non verbal.
As for the comment on the abnormalitiy seen on the lateral view, I noticed the same thing (and I thought the right hilar area looked a bit full so I got a CT. I'll post the images tomorrow when I get in.

Anonymous said...

you pt mental status decline was related to his profound hyponatremia. find the cause of the hyponatremia and reverse it, tx with 3% NaCl to slowly bring the level up