This is a case study involving an elderly female with complex medical history who presented with altered mental status of unclear etiology. The patient in this case is unable to give a history.
There are no reliable sources who witnessed the events leading to patient presentation making it more difficult to ascertain the etiology of her condition. The author hopes to elicit a discussion of her case among peers in critical care nursing.
Background / Social History
RS is a 70-year-old female who lives independently in a first-floor apartment in the city. She has no close relatives but has neighbors who know her very well and check in on her from time to time. She hires a cleaning lady that does her house cleaning and laundry every week. Her nearest relative is a niece who lives in the same state but is 8 hours away by car.
Past History
Her medical history includes anxiety disorder, hypertension, hyperlipidemia, COPD, and mild kidney insufficiency.
She has a 40 pack/year history of smoking.
She has no known allergies.
Medications
Paroxetine 20 mg daily
Lorazepam 1 mg daily as needed for anxiety
Losartan 100 mg daily
Amlodipine 10 mg daily
Simvastatin 40 mg daily
Tiotropium 18 mcg inhaled daily
Albuterol MDI 2 puffs 4 times a day as needed
Present History / CC
On the day of her ED admission, her niece had been calling her phone and had been unable to get hold of her. Her niece called a neighbor who stated that she has not seen RS in 3 days. Concerned about RS's condition, the neighbor knocked on her door and heard no response. Luckily she was able to open the door as it was unlocked. Upon entering the living room, the neighbor found RS lying unconscious on the floor. She had frothy secretions from her mouth and had urinated on herself. She immediately called 911. She was intubated at the scene by EMS responders for airway protection due to her altered mental status.
Vital Signs
BP 180/100
HR 110
RR 32
T 38.5 C
O2sat 88% on RA prior to intubation
Diagnostic Studies
In the ED, RS pertinent labs showed a WBC of 15,000 mm3, a lactate of 2.5 mmol/L, and CPK of 20,000 U/L. Neurologic exam was significant for agitation and inability to follow commands with sedation wean. She was hyperreflexic with increased muscle tone. She is moving all her extremities equally and has no abnormal pupillary response. She is sedated on Propofol. CV exam reveals sinus tachycardia with BP of 110/50, her skin is warm to touch. Respiratory exam reveals rhonchi in upper lung fields with moderate white secretions via ET tube
ABG: 7.36, 38, 82, 19, -3, 100% on ACVC: 16X400, FiO2 of 0.5 PEEP of 5.
CXR reveals mild cardiomegaly, a hyperinflated lung silhouette and mild RLL opacity.
Non-contrast CT Scan of her brain showed focal vasogenic edema in the basal ganglia.
The remainder of the exam revealed normal findings.
The ED was particularly busy that evening so RS was immediately transferred out to ICU without further testing in the ED. Because of her complex medical condition, she was transferred to the MICU under your care as her primary RN.
What thoughts run in your head that could possibly explain what caused RS's presentation?
What further testing would you anticipate?
How would you care for RS as her nurse?
For this exercise to be fun and informative, answer in the following manner:
List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why.
Tests you would anticipate.
Interventions you would provide as the bedside nurse and why.
Note: This is an actual case and the outcome is already established.
