Case Study: Solve A Neurologic Mystery

Will give this a try...

My first thought was carbon monoxide poisoning, but I decided on this.....

1) Cardiac arrhythmia that converted itself/MI (elevated CPK), possibly secondary to some electrolyte imbalance (hyperreflexia, increased muscle tone, agitation), that led to passing out, loosing bladder control, and hitting her head (vasogenic edema) leading to further decrease in LOC. Plus pneumonia/sepsis (increased WBC, lactate, agitation, sputum, Rhonchi) (which is not helped by smoking all those years and COPD) contributing to compensated respiratory acidosis (which is probably somewhat already existing because of COPD) and decreased LOC, maybe she has left sided heart failure too that lead to pulmonary edema (frothy sputum).

2) Troponins, Pro-BNP, blood cultures

3) elevate head of bed, suctioning, monitor for signs of sepsis and arrhythmias, electrolyte replacement, ABX, monitor for decreasing LOC

Thoughts?

Edited Jun 17, 2013 by Lev <3

I have no clue as I'm a new grad but this is really interesting

I was thinking possible CVA - and also was she suffering from rhabdomylosis from laying for so long?

Rhabdo?

This is really interesting.

Perhaps she seized secondary to a CVA and aspirated, causing PNA and what seems to be sepsis. Looks like rhabdo too.

Blood cultures, IVF, and get a dose of antibiotic in ASAP.

Ehhh...Serotonin syndrome?

She is on multiple meds that should be used with caution in the presence of renal insufficiency, causing electrolyte imbalance followed by altered LOC. She goes unresponsive and develops pneumonia from lying on the floor for extended period. She has now become septic.

Full urine and blood screen including drug screen. CT/MRI to rule out CVA and possible fractures. Obtain a better history of the patient prior to last known normal from neighbors and daughter.

Monitor ABC's, V/S, watch for cardiac dysrhythmias, change in neurological status because these things can change quickly in the presence of sepsis. Monitor effects/side effects of any treatments that are already being provided. IV antibiotics for pneumonia.

Thinking about serotonin syndrome also. An over dose of her paxil may have caused it.

Aspiration pneumonia secondary to new onset seizures. A CVA. Basal Ganglia disease. High ammonia levels? Liver disease. (and I would throw in there has she been drinking ETOH? Any hidden bottles in her home?) Seratonin syndrome.

I also would want more information regarding her ability to take on a regular basis her meds at home--has she taken them regularly? This information could be helpful in determining if her BP has been out of control for any length of time.

I would expect serial triponins, liver profile, ammonia levels. EKG, on the monitor to check for any arrythmias. Blood cultures--what was her temp? Urinalysis and culture. Finger stick for blood glucose.

Keppra as a precaution, IV antibiotics. Not sure what to do about the Paxil, as abrupt stop is not encouraged. Better blood pressure control.

This is really an awesome exercise. Would love to know what it ended up being, and what happend with this patient.

I wanted to say CVA but that seems like the easy answer. After reading the other responses and doing a little research it looks like we may have a zebra here instead of a horse. :)

UTI giving stroke like symptoms that then caused fall that in term caused a rhabdo. Pneumonia from either stasis or aspiration, or both.

1. List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why.

2. Tests you would anticipate.

3. Interventions you would provide as the bedside nurse and why.

hmmm

some sort of stroke may be possible, though she is moving all ext....

some sort of poisoning, I would hope they have done or are doing a tox screen. including CO poisoning.

2)the above, plus ? environmental issues, ie was the apartment recently sprayed? presence of mold...etc

3) symptom mngmnt. physical positioning to ease breathing, meds per order for fever is any. restraint free as possible, esp if rhabdo is a serious concern.