History of Present Illness:

A woman in her 70s with a history of dementia is signed out to you after 120 hours in the ED waiting for Geri-psych placement.  You are told she is medically cleared and they are hoping to get her a bed later that day.  You hear her occasionally screaming and joke/ask the nurse if she needs anything.  You are told “she has been doing that for days” but she is delirious and “you just have to ignore her.”

Vital Signs & Physical Exam:

Vital signs are normal except for a BP of 161/99.   Physical exam is notable for her being agitated and tangential, but non-focal.  Her mouth looks a bit dry.  Her breakfast tray looks untouched.  When you ask if she is hungry, she replied “The food here stinks!”

Initial Diagnostic Testing:

  • CBC: normal
  • Chem 7: normal except for glucose 131
  • Imaging: CT head normal.  CXR normal.
  • UA: 10 WBC, few bacteria

What should you do?

  • A) Wait for her to get placed and/or sign her out after your shift
  • B) Repeat labs as it has been 4 days
  • C) Give antibiotics and check urine culture
  • D) Sedate her

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWER:

  • A) HSV: only about 50% of cases have a high RBC count
  • B) Cocci: CORRECT – causes pneumonia (easy to treat) and meningitis, (hard to treat).  More common in immune compromised patients, including DM
  • C) Crypto: doesn’t usually cause pneumonia and rare outside HIV
  • D) TB: can cause lung and CNS disease but should leave scar on CXR and not typically called “fungal”
  • E) Bacterial: can cause lung and CNS disease but not typically called “fungal”

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CASE CONCLUSION: given Rocephin, vanco and IV fluconazole all at high doses after decadron and admitted.  CSF culture results: Crypto Ag and Cocci Ab in CSF both negative.  However CSF Cocci titer is known to be unreliable.  A serum titer was positive at 1:8.  She improved on IV fluconazole and was transitioned to PO and discharged with ID follow up.

CASE LESSONS:

  • History is key.  Headache is a common additional symptom that is not usually that important to dig into, but sometimes it is.
  • If when you enter a room the patient keeps there eyes closed or face covered, it could be drama or a migraine but always consider more dangerous reasons such as meningitis or even vertigo from a stroke.