My mystery patient

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Specializes in Neuro, Critical Care.

Thoughts anyone? This is my patient for tommorrow. Any thoughts would be appreciated. Im trying to figure out what to do my prepwork on, ie what diagnosis... This is info I received from my team leader over the phone. I was thinking TIA/stroke but her CT was negative? Although I didn't get to see the whole report. Just getting some other opinions! Thanks:)

Unresponsive

6/23-pt. found unresponsive/posturing and frothing at the mouth

Intubated, fell the day before in bathtub

Neuro eval. Biting e tube, vent

25-still unresponsive

26 moves all extremitites

27-more responsive, neuro improving

HX: COPD/ESRD/HTN/Chronic anemia, Hyper lipidemia type I diabetes, asthma, O2 at home at night, GERD, TIA, peritonitis 3/06, PD x 2 years, HD started, tues/thur/sat

RUchest dialysis tunnel cath

Neuro checks q4h

Salem to constant low wall suction

Labs: chloride 96 L

Glucose 132 H

BUN 156 H

Cratinine 10.7 H

Calcium 7.8 L

Hb 11.0 L

MCHC 31 L

RDW 20. 4 H

CT 6/24 negative

EEG rule out infarct 6/24 results not back yet

ECHO r/o endocarditis 6/27/06 results not back yet

MEDS:

1500 Lopressor 25 mg NG

1700 Zoysn 2.25 g IVPB over 30 min

1800 50 mg Cozaar PO

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Specializes in IMCU/Telemetry.

Looking at her BUN and Cratinine, she looks toxic. She needs Hemo now. It sounds more like a seizure to me.

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Specializes in Neuro, Critical Care.
Looking at her BUN and Cratinine, she looks toxic. She needs Hemo now. It sounds more like a seizure to me.

cool thanks.

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Are WBC elevated? Infectious process- meningitis or encephalitis- might be the culprit. BUN and Creatinine can normally be this high in a chronic hemodialysis patient.

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Specializes in Neuro, Critical Care.
Are WBC elevated? Infectious process- meningitis or encephalitis- might be the culprit. BUN and Creatinine can normally be this high in a chronic hemodialysis patient.

They might have been. My team leader didnt say they were and I imagine that she would have told me. We are supposed to get all the abnormal labs.

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If your pt. is not stable enough for hemodia. they may consider CVVHD with a creat. that high they will have to do something.

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Specializes in Trauma, Teaching.

Since she fell the day before, you might want to consider a subdural hematoma, that hasn't yet shown up on CT.

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Specializes in Neuro, Critical Care.
Since she fell the day before, you might want to consider a subdural hematoma, that hasn't yet shown up on CT.

that was my original thought. How long does it take for a sub. h. to show on a CT? I would have thought if she fell on 22th that it would show up by 24th? I was really thinking some sort of stroke, hemm. and was suprised when the CT came back neg.

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She definitely had a seizure causing her to come in to hospital, but the head trauma from the fall in the bathroom is what caused the seizure. Problem is 2-3% of all brain hemorrhages (excuse my spelling!) are NOT seen at CT, sometimes not at all. If it was a subdural it would probably grow and would show up by now. If it is a subarachnoid hemm or an intracerebral hemm it may take cerebral angios for diagnosis and/or treatment. You client is in imminent danger if they do not receive further neuro evaluation. Even a an LP would indicate a SAH. How do I know these things, I work in emerg but also in neurosurgery!! And as we know any injury or insult/irritation to the brain can cause seizures causing me to have a high index of suspicion that something is still going on in there.

:)

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Specializes in Ortho/Neuro.
Since she fell the day before, you might want to consider a subdural hematoma, that hasn't yet shown up on CT.

That's what I was thinking too.

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Specializes in ICU, Education.

I agree with phenomenon that patient likely had a seizure. did she fall the first time because of seizure? might be a question, or did the head trauma cause the seizure? What was her sodium level on admit?? with her renal failure obvious by her BUN and Creat it makes me wonder if her sodium couldn't have been critically low to cause a seizure. Also the EEG should be to R/O seizure not infarct. I am surprised that they haven't repeated her CT scan or done an MRI by now. many things will not show up on the inital CT scan the will show up in 48-72 hours later-- like a Subdural hematoma, or ischemic stroke

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