I'm Dizzy, Tired and Can't Remember What I Ate for Lunch

A 74-year-old white male presents to the ED with confusion, fatigue, dizziness, headache and distal right arm paresthesia. Experienced nurses, model your clinical judgement skills for students and newbies by posting some priority actions.

Updated:  

This article was reviewed and fact-checked by our Editorial Team.
I'm Dizzy, Tired and Can't Remember What I Ate for Lunch

Chief Complaint

Headache, dizziness, right distal arm paresthesia 3-4 days, confusion, recent history of mental impairment along with bradyphrenia (mild cognitive impairment or slowed thinking and processing of information).

History of Present Illness

A few months before the ED visit, I spoke with him on the phone and he said, "I'm just so tired all the time. I can't even walk across the driveway to the barn without feeling exhausted.” He finally admitted that he had stopped taking medications for hypertension and hyperlipidemia during the COVID-19 pandemic. "I just quit. I didn't feel like taking them.”

A few days ago, he told his wife he was feeling dizzy and that something was "not quite right", but he refused to go to the ED. This evening, he asked to come to the ED after experiencing increased dizziness, headache, and numbness in his hand. His wife tells the ED nurse, "He's been having a hard time remembering things.”

General Appearance

Well-developed, well-nourished, resting comfortably, breathing comfortably on room air.

Past Medical History

Hypertension, hyperlipidemia, pre-diabetes, glaucoma with ocular implants, excess EtOH consumption (greater than 2 drinks/day for men)

Family History

Father died from colon cancer at the age of 80. Mother died of cervical cancer at age 63. No siblings. One biological daughter, age 53 with no health concerns. His step-son works in the hospital and stops by during the visit.

Social History

The patient has been married to his third wife for twenty-five years. He lives on a farm and has taught at a local college for many years. This last year he has been teaching from home. His hobbies include playing the banjo and gardening. They raise llamas, so he works in the barn and fields when he isn't teaching.

Patient drinks 2-3 alcoholic beverages daily and occasionally smokes marijuana (it is legal in his state).

Medications

lisinopril-HCTZ 20-12.5 mg daily, metoprolol 25 mg BID, COSOPT, XALATAN ophthalmic, atorvastatin 80 mg. Patient states he started taking all of his medications again about two months ago.

Allergies

NKA

Vital Signs

  • BP 208/97 sitting, RA
  • Pulse rate 63
  • HR 56
  • RR 19
  • T 98.8o F
  • SpO2 98%
  • HT 5' 11"
  • WT 210 lbs
  • BMI 29.9

Dizziness, headache, confusion, fatigue – these are symptoms of SO MANY PROBLEMS – what else do you notice? What else would you like to know?

I've been working on preparing my students for the Next-Gen NCLEX, so I'm thinking a lot about clinical judgment and prioritization.

What's the first thing you need to do?

Is there anything emergent going on?

As the Nurse, what are your priority actions?

Since you can't post your guesses here, I'm hoping you Nurses out there will model your critical thinking by showing the students and newbies your thought process (thanks in advance!)

DISCLAIMER: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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Specializes in Community health.

How is his kidney function?

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My immediate response would be to r/o a stroke, check kidney functions, check for any tick-borne illness since he works with animals outside. 

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Check glucose, kidney/liver fx, ammonia, and troponin levels.

ECG, EKG.

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18 hours ago, artsmom said:

My immediate response would be to r/o a stroke, check kidney functions, check for any tick-borne illness since he works with animals outside. 

And water born illnesses, if the farm has a pond.

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Specializes in Public Health, TB.

Neuro check including cranial nerves, Head and chest CT scan once kidney function is assessed. As long as your getting blood, draw a rainbow. 

Check BP in both arms, assess chest sounds esp for murmurs and bruit. 

For nursing students, what is going to kill you fastest? A,B,Cs. 

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EKG, Labs, Blood glucose, Urine sample for lab, do an assessment, order chest x-ray if warranted, 

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Specializes in Education, Informatics, Patient Safety.

FOLLOW UP #1

Hey folks! Thank you so much for your comments. I'd love to hear more from you about HOW you decide what is a priority - what is your thought process for deciding what information to ask for? What clues are helping you, alerting you, making your Spidey sense tingle?

After further conversation with the patient’s son and wife, it is revealed that he has had confusion and memory loss for 4 weeks. He is given ASA 325 mg at ED with orders to continue on 81 mg ASA and is admitted to the cerebrovascular neurology service for workup. Further orders include to permit hypertension up to 220/110 for first 24 hours with PRN hydralazine 50 mg q6hr PO. Hold home antihypertensive (lisinopril-HCTZ 20-12.5 mg daily); resume half dose beta blocker with holding parameters – received full dose of metoprolol 100 mg at ED, resume with BID 25 mg, heparin 5000mg sq.

Recall the purpose of permissive hypertension (usually no more than 24 to 48 hours) is to widen blood vessels and improve blood flow in the brain.

EKG normal

Orders: Stroke risk factor work up: HbA1c, fasting lipid panel, CBC, Metabolic, liver function panel, TSH, Neuro checks, Cardiac monitoring

Review of Systems: Lungs clear to auscultation bilaterally, Cardiac regular rate and rhythm, abdomen soft, non-tender, non-distended, skin – no rash on exposed skin

Neurologic exam

No appreciable neurological deficits aside from frequent pauses when trying to convey the course of his current complaints and distal right arm tingling sensation predominantly affecting the hand.

  • Mild aphasia with difficulty naming objects
  • No dysarthria
  • Cranial nerves intact
  • Motor – full strength, normal tone
  • Reflexes – normal and symmetric
  • Coordination: no ataxia on finger-to-nose or heel-to-shin bilaterally
  • Sensory: intact to pinprick, no evidence of neglect
  • Gait: normal, turns without shuffling

Kokmen Short Test of Mental Status (to assess for dementia or cognitive issues):

  • Orientation 7/8
  • Attention 7/7
  • Recall 4/4
  • Calculation ¾
  • Abstraction 2/3
  • Construction 2/2
  • Copy 2/2
  • Information ¾
  • Recall 0/4

Total 30/38

A score of 29 or less detects dementia with a high level of sensitivity.

NIH Stroke Score

Stroke score was 1, for very mild ataxia of upper left limb. Otherwise unremarkable with mild/improving symptoms, no IV thrombolytics given

Laboratory Test Results (normal values):

  • Na 141 meg/L (135-145)
  • K 4.2 meq/L (3.5-5)
  • Cl 106 (101-112)
  • Mg 2.1 mg/dL (1.8-3)
  • BUN 18 mg/dL (8-20)
  • GFR >60
  • Cr 1.1 mg/dL (0.6-1.2)
  • Ca 9.7 mh/dL (8.5-10.5)
  • Hb 16.8 g/dL males (13.6-17.5)
  • Hct 49.1% males (39-49%)
  • Plt 177,000 cu/mm (150,000-450,000)
  • WBC 6.8 x 103/mm3 (4,800- 10,800)
  • Neutros 74.8% (57-67)
  • Lymphs 15.7% (25-33)
  • Eos 1.6% (1-4)
  • Monos 6.9% (3-7)
  • Basos 1 (0-1)
  • RBC 5.39 (4.3-5.7 M/uL)
  • MCV 91.1 fL (81.2-95.1)
  • MCH 31.3pg (26-32)
  • MCHC 34.4 g/dL (32-36)
  • RDW 11.1% (11.8-15.6)
  • AST 30 IU/L (0-35)
  • ALT 45 IU/L (7-56)
  • Alk phos 78 U/L (38-128)
  • Glu fasting 153 mg/dL (60-110)
  • Total Bili 1.5 mg/dL (0.1-1.2)
  • Total Protein 7.5 g/dL (6-8.3)
  • Albumin 4.9 g/dL (3.4-4.7)
  • TSH 3.5 mIU/L (0.5-5)
  • FT4 1.2 ng/dL (0.7 - 1.9)

Urinalysis: Specific Gravity 1.020 (1.000-1.030) trace blood in urine, pH 5.5 (5-7)

Passed bedside swallow study

CT ordered

 

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All of the above, except I would add a psych(depression?) and neuro consults (dementia or ETOH induced pathology?) 

I would explore depression because of age, appears to be alone and increased anxiety re Covid and poor med compliance( social groups?) . Older men also tend to have residual anger issues(political) which could be tied into depression. Getting older, diminished capabilites, unresolved issues, increasing frustration, online activity? social groups misinformation?etc. Any religious or psychological anomalies caused from Covid or political misinformation. He is a teacher and probably educated, but where is getting current information from?

Depression might cause sleep problems resulting in extreme tiredness. 

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Specializes in BMT/blood cancers.
SafetyNurse1968 said:

What is his HbA1c?

Hct/neuts=increased—rule out lymphomas/Leukemias or lymphomas (fatigue, headache)

albumin/Bili=Increased—rule out liver issues possibly r/t ETOH 

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Specializes in BMT/blood cancers.
On 9/6/2021 at 4:59 AM, SafetyNurse1968 said:

Edited*

What is his HbA1c

Hct/neuts=increased—rule out lymphomas/Leukemias or lymphomas (fatigue, headache)

albumin/Bili=Increased—rule out liver issues possibly r/t ETOH 

serum (and/or CSF) protein Electrophoresis—rule out possible MS; myelodysplastic syndromes 

Other labs to add:

coags

LDH 

Uric acid 

Erythrocyte sedimentation rate (ESR) 

Total protein levels

Albumin-to-globulin ratio

Maybe?Rheumatoid factor, cryoglobulins, direct antiglobulin test, and cold agglutinin titer results 

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Specializes in Education, FP, LNC, Forensics, ED, OB.

This Case Study is rapidly heading towards conclusion.

Post your guess for the diagnosis in the Help Desk!!

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