The 43-year-old woman walks into the medical emergency department naked and confused at 215 in the morning. On initial triage, vital signs are stable, but the patient appears to have an unsteady gait and tremor.

The 43-year-old woman walks into the medical emergency department naked and confused at 215 in the morning. On initial triage, vital signs are stable, but the patient appears to have an unsteady gait and tremor. The patient vomits shortly after being seen. She is oriented person only, unaware of her location, the date, or any of the events leading up to her presentation. She cannot provide her address or any identifying information, except to mumble” Depakote, lithium, Tegretol, lots,” when asked what medications she is taking. She is confused at several points during the interview but never lethargic, and her thought processes are disorganized. She repeatedly laughs inappropriately and does not appear concerned by the fact he has arrived without clothing. She remains calm in the ER but does not understand why is there or how she arrived. No prior charts are available to review the history, and the patient is unreliable due to confusion and unable to provide contact information.

It was a cold evening, with a temperature of approximately 40°F, and the patient is noted to be shivering. There are no other signs of hypothermia, and there is no evidence of bruising or physical trauma. Blood is drawn and a psychiatric consult is called.

Mental status examination:

The patient is well groomed despite being without clothes. She is wearing hospital pajamas and covering herself with a blanket around her shoulders. She sits calmly in a chair and is cooperative with the interview. Her speech is soft, mumbling, dysarthric, and almost incoherent at times. Her psycho motor behavior is affected by a tremor, but no other abnormal movements or is any agitation, observed. She appears euthymic and seems to understand questions related to her mood. Her affect is inappropriate at times; she smiles oddly with frequent laughing. Her thought processes are disorganized; she does not answer the questions directly and goes off on tangents or includes many irrelevant details in her responses. She appears internally preoccupied during the interview, frequently staring into space, although it is difficult to assess directly whether she is experiencing auditory hallucinations. There is no evidence of suicidality or homicidality based on observations in the emergency rooms. She is alert but oriented to person only; she is able to name the month but gives the wrong date and day of the week. She is able to name the city but does not know that she is in a hospital and cannot identify or locate.

Physical examination:

Temperature, 36.7°C; heart rate 55 beats/per minute; blood pressure 130/; respirations 18.

General: she is well-nourished, well appearing adult in no apparent distress  HEENT: no evidence of head trauma. Pupils are equal and reactive to light, extra ocular movements are intact, and the oropharynx is clear. Oral mucous membranes are dry, and there are no signs of goiter or JVD. Cardiac: decreased rate to 55 bpm but regular rhythm with no murmurs, gallops, or rubs. Chest: clear to auscultation bilaterally. Abdomen: soft, nontender, not jdistended, with positive bowel sounds. Extremities: no signs of clubbing, cyanosis or edema.

Neurologic examination:

Mild ataxia, of course tremor, hypereflexia. Cranial nerves 2-12 are intact, but nystagmus is observed; strength is 4/5 upper and lower extremities; sensation is difficult to test; coordination is impaired.

Diagnostic testing:

CT of the brain: no signs of mass, bleeding or infarct. EKG: normal sinus rhythm at 58, with T wave flattening. E.EG: diffuse slowing, no seizure foci.

Laboratory examination:

CBC showed elevated white blood cells to 12.3, with no left shift. Chemistry showed mild dehydration; serum toxicology was negative. Liver, thyroid function tests, and UA were within normal limits. Carbamazepine and valproic acid levels were undetectable. The serum lithium level was 2.3mEq/ml. Alcohol level was negative.

Questions

What is the most probable cause of the patient’s confusion? Explain your answer.

•             Any differential diagnoses

•             Your diagnosis and reasoning

•             Any additional questions you would have asked

•             Medication recommendations along with your rationale. Note possible   side effects or issues to address if attempting to obtain consent.

•             Any labs and why they may be indicated

•             Screener scales or diagnostic tools that may be beneficial

•             Additional resources to give  (Therapy modalities, support groups, activities, etc.)

CASE 2

A 74 year old gentleman presents to your office with a 20 year history of depression.  He is accompanied by his wife of 50 years.  His family is concerned because he has begun to exclude himself from routine family activities.  He is a retired police office but has remained part of the community despite his multiple medical complications.  Most specifically is a femoral popliteal graph with a “rubber” vein that has led to chronic venous insufficiency and more importantly chronic intractable pain.  Over the years he has tried all of the SSRI’s and is currently taking Wellbutrin XL 300mg and Gabapentin 900 mg tid. He also takes a BID dose of Oxycodone but is still unable to sleep for more than 2-3 hours at a time due to his pain. He has also tried Elavil in the past without relief.

What is your primary concern with this gentleman?

Please include the following:

•             Any differential diagnoses

•             Your diagnosis and reasoning

•             Any additional questions you would have asked

•             Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

•             Any labs and why they may be indicated

•             Screener scales or diagnostic tools that may be beneficial

•             Additional resources to give  (Therapy modalities, support groups, activities, etc.)

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.