Patient presenting with altered mental status

Thaer Ahmad M4

August 28th, 2013

Contributing Resident: Dr. Urvi Tallor

• CC: 62 year old male who presents with altered mental status.

• Patient is presenting with worsening confusion & somnolence.

• PMH includes Hepatocellular carcinoma, Hepatitis B, Cirrhosis, Diabetes, and HTN.

• Patient recently discharged for similar presentation; found to be secondary to hepatic encephalopathy and was discharged on Lactulose.

• Current concern for infection precipitating altered mental status. MRN: 6018231

Clinical History

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• Vitals: BP: 117/73 mmHg Pulse: 76 Temp: 97.9F Resp: 12 SpO2: 98 %

• Physical exam is within normal limits• Lungs are clear to auscultation bilaterally• Patient o

H&P Continued

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btunded and unable to answer questions relevant to history and current presentation

• Pneumonia• Spontaneous Bacterial Peritonitis• Pharyngitis• Essentially any infection given low

immunocompetence of patient.

Differential Diagnosis

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• WBC: 5.16 Hgb: 10.2 Hct: 29.2 PLT: 71• Glucose: 167• PT: 13.3 PTT: 30.0 INR: 1.25• Paracentesis: <250 WBC count

Relevant Labs

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• CXR ordered to investigate possible infectious etiology

What should we do next?

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Is CXR the appropriate diagnostic test?

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Chest X-Ray Supine Frontal view (Portable)

Closer Look….

Left lower lung base opacity

-Pneumonia (#1)

-Atelectasis (#2)

-Pulmonary Edema

-Pulmonary hemorrhage

New Differential

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Additional Imaging?

-AP/Lateral X-ray to further investigate consolidation.

-Patient admitted and treated for possible pneumonia. Given IV antibiotics (Levofloxacin 500mg once daily)

-Patient also given lactulose

-Patient’s mental status improves

-Patient is asymptomatic, afebrile, and reporting improvement.

-New Chest X-ray ordered

-Patient being evaluated for liver transplant

Treatment and Outcome

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Chest X-ray, upright, AP/Lateral, Frontal view

Chest X-ray, upright, AP/Lateral, Lateral view

Comparison

Resolved After Antibiotic TxPatchy DensityPossible Pneumonia

Discussion

• Clinicians arrive at the diagnosis of pneumonia by incorporating clinical judgment, radiological imaging, and diagnostic labs

• Presence of an infiltrate on plain chest radiograph is the gold standard for diagnosing pneumonia

• For hospitalized patients with suspected pneumonia and a negative chest radiograph, the 2007 IDSA/ATS consensus guidelines consider it reasonable to initiate empiric presumptive antibiotic therapy and repeat the chest radiograph in 24 to 48 hours

• CT scanning is not generally recommended for routine use because the data for its use in pneumonia is limited, the cost is high, and there is no evidence that it improves outcome

Thanks for listening