Altered Mental Status | Figure 1

petrilloanthony

Emergency Medicine Resident

Altered Mental Status

The patient is a 60 y/o F with no reported past medical history who presented to the emergency department obtunded after being last seen normal by family about 24 hours prior. She was febrile and tachycardic (consistent with SIRS).

Diagnosis added by author

Bacterial meningitis

More about this case

Similar Cases

I was participating on another post and this topic came up, luckily enough, I saw this patient this week in the clinic, so I wanted to bring this case with some valuable learning points, I think....

33F born in India but immigrated to Canada in 2014. Last year had a miscarriage. PMHx significant for Epilepsy, on Carbamazepine 300mg at night time for many years, has been seizure free since 2020. At that time (2020) she had 2 GTCs in a context of sleep deprivation (studying for her MSc exams) and missing medication for 2 days. Prior to this, when she was growing up and up to highschool, she would have numbness and clusiness on left arm (always left) followed by staring off episodes that lasted for a few seconds. No automatisms, these were happening once every 3-6 months. So far, so good, right? Well, now she is 5 weeks pregnant. She has a new PCP and they referred her right away to Neurology due to last failed pregnancy and on Carbamazepine. MRI is shown, please forgive my pulse I'm clearly not a good drawer, but I wanted to highlight the problem, as it is subtle. Back home, they did workup years ago and told her she had Neurocysticercosis, and seizures as a consequence of that "scar in the brain". When she came to Canada, she was referred to a local Neurologist who tried to switch her to Keppra, but she developed dizziness and foggy mind, hence, she advocated herself to continue on Carbamazepine until today. What would be your next steps considering:

On the pictures, you can see the bubble graph with the % of teratogenicity with different anti seizure meds in the bubble graphic. As you can see, CBZ is not the safest option, the risk is moderate (4-6%). You can see on the blue circle graph better options available with lesser risk, however one could argue she has been seizure free, and now she is pregnant, hence we need to avoid a GTC at all costs as this can be detrimental to the fetus, especially this early in pregnancy. Moreover, class switch while pregnant is not something we would advocate (unless extremely necessary), but within class, we would consider doing an overnight switch, as an outpatient (for example, CBZ to Oxcarbazepine, in this case). Oxcarbazepine has a better teratogenic profile than CBZ.

a 2 year old child came to the ER with his mother..the child was convulsing..and the mother said that he complained of high fever last few days until today when suddenly he started convulsions just minutes before presentation...the child wasn't cyanotic and the vitals were within normal without any other symptoms or abnormalities... what is the probable diagnosis and how to proceed?

A 24 Y/O F Pt., previously healthy, underwent tooth extraction 2 wks ago which got complicated by infection and abscess formation. Despite drainage and antibiotic coverage, she is febrile and started to LUQ pain CAT scan showed multiple large splenic abscesses She is scheduled for splenectomy

Disseminated meningococcemia #Purpura-fulminans

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family, are there any features in this ekg that would warrant further work-up or is this just a pediatric ekg?