RT Book, Section
A1 Nelson, Lewis S.
A1 Howland, Mary Ann
A1 Lewin, Neal A.
A1 Smith, Silas W.
A1 Goldfrank, Lewis R.
A1 Hoffman, Robert S.
SR Print(0)
ID 1163016835
T1 Case Study 6
T2 Goldfrank's Toxicologic Emergencies, 11e
YR 2019
FD 2019
PB McGraw-Hill Education
PP New York, NY
SN 9781259859618
LK accessemergencymedicine.mhmedical.com/content.aspx?aid=1163016835
RD 2024/04/18
AB HistoryA  78-year-old  man  presents  to  the  emergency  department  after  his  family  found  him  to  be  acutely  confused.  The  family  states  that  he  was  in  his  usual  state  of  health  until  one  day  prior  to  presentation.  The  patient  had  not  complained  of  nausea,  vomiting,  diarrhea,  or  abdominal  pain.  The  family  is  unaware  of  any  new  medications  that  the  patient  might  have  been  prescribed  or  any  new  exposures.Physical  ExaminationOn  presentation  to  the  emergency  department,  the  patient  appeared  confused  and  disoriented.  Blood  pressure,  140/70  mmHg,  pulse,  115  beats/min,  respiratory  rate,  26  breaths/min;  oxygen  saturation,  94%  on  room  air,  and  tympanic  temperature  38.2oC  (100.8oF).  The  physical  examination  demonstrated  dry  mucous  membranes  and  clear  lung  sounds  with  crackles  at  the  bases;  his  neurologic  examination  was  nonfocal.  He  was  not  following  commands,  but  appeared  to  be  moving  all  extremities  with  equal  strength.Initial  ManagementGiven  the  elevated  temperature  and  the  confusion,  the  medical  team  was  concerned  that  the  patient’s  delirium  had  an  infectious  etiology  the  point  of  care  glucose  was  normal,  and  they  ordered  a  noncontrast  head  CT,  chest  radiograph,  venous  blood  gas  with  a  lactate  concentration,  basic  metabolic  panel,  hepatic  function  tests,  a  complete  blood  count,  urinalysis,  and  blood  and  urine  cultures.  The  patient  was  empirically  started  on  broad-spectrum  antibiotics;  and  1  L  of  0.9%  sodium  chloride  solution  was  administered  intravenously  over  30  minutes.  Pertinent  laboratory  results  included  a  urinalysis  with  1+  leukocyte  esterase  and  trace  ketones  and  basic  metabolic  panel  with  an  anion  gap  of  18  mEq/L.  The  blood  gas  analysis  revealed  a  pH  7.46,  PCO2  22  mm  Hg,  HCO3–  14  mEq/L,  and  lactate  3.5  mmol/L.What  Is  the  Differential  Diagnosis?Confusion  and  delirium  are  common  ­reasons  for  elderly  patients  to  present  to  the  emergency  department.  Often,  an  ­infection  is  the  etiology  for  the  acute  onset  of  delirium.  However,  older  patients  often  suffer  from  several  chronic  conditions,  and  are  taking  multiple  medications,  enhancing  the  risk  of  drug-induced  adverse  effects,  including  drug-induced  delirium.  Furthermore,  some  patients  have  underlying  dementia  and  can  inadvertently  take  too  much  of  their  own  medication  (Chap.  32).In  recent  years,  there  has  been  an  increase  in  the  prevalence  of  illicit  substance  abuse  and  prescription  drug  misuse  in  the  older  population,  which,  along  with  alcohol  misuse,  may  be  clinically  unrecognized.  In  patients  who  present  with  confusion,  elevated  temperature,  tachycardia,  and  hypertension,  it  is  important  consider  ethanol  withdrawal  in  the  differential  diagnosis  (Chap.  77).  A  full  drug  history  should  include  prescription  and  nonprescription  items,  and  non-oral  drugs,  including  drug-releasing  patches.  Numerous  drugs  are  available  as  transdermal  patches,  and  incorrect  use,  such  as  application  of  multiple  patches,  can  lead  to  toxicity.  Therefore,  the  patient  must  fully  undress  and  be  placed  in  a  gown  for  a  thorough  physical  evaluation.  Anticholinergic  patches  are  common  as  a  treatment  for  vertigo  and  motion  sickness  (Chap.  49).  Patients  who  have  signs  of  anticholinergic  toxicity  can  present  with  an  altered  sensorium  and  an  elevated  temperature,  which  can  initially  be  mistaken  for  sepsis.What  Clinical  and  Laboratory  Analyses  Help  Explain  the  Causes  of  This  Patient’s  Presentation?A  geriatric  patient  who  presents  with  confusion  should  be  evaluated  for  medical  causes  of  ...