87 yo with altered ms

[erinto]

CM, an 87 yo white male presents to the emergency room for altered mental status.    Patient's wife states he had an upset stomach for a few days, with some mild diarrhea, no vomiting, no fever.   Today, he "isn't acting right", so she called 911.
On exam, you see an acutely ill 87 yo male, lethargic, tachycardic, pale.   He moans on exam when you ask his name.   VS: 98.7 oral, 178, 112/82, 26.     Lungs are clear, but diminished.   PERRLA, MM dry, tachy, but regular, good pulses in all four extremities, abdomen is slightly distended, soft, tender in upper abdomen.   He has been incontinent of stool.   It is brown, non bloody.   

Hint: check a rectal temp

and GO

[Bjs04f]

so AMS, tachy, normal BP, tender abdomen. What was his temp. Any med history.

[Bjs04f]

Sinus tach, or afib?

[jpollock]

meets sirs criteria between HR and RR, so rectal temp, lactate, cultures just in case. But gotta worry about all kinds of bad stuff like perf, GB, AAA, etc

[erinto]

His rectal temp was 107.7, one of the highest I had ever seen. So, he got the full septic work up. He was only on two meds, one for hypertension, and one for cholesterol, a VERY healthy 87 yo. The only history I could get from his wife was that he had been having some stomach pain, but she wasn't sure where it was or when it started. She did not know he had a fever.

This case illustrates several points, but the first one is, when in any doubt, rectal temp is warranted. Some nurses push back, because they are a pain, but they can be very helpful. His heart was going so fast, I could not see the underlying rhythm. I wasn't sure if it was a fib RVR, SVT, or sinus tach, so I gave adenocard to slow him down, and the P waves were evident, so I felt it was a sinus rhythm, just ungodly fast due to fever. He was given rectal tylenol when we got his rectal temp, IVF, blood cultures, lactic, urine, urine culture, ABG, CXR, and the usual labs.

WBC 2.2 with 7.0 bands, Na 132, K 3.2, cl 103, CO2 21, BUN 23, Cr 1.4, glucose 161, total protein 5.8, albumin 3.0, alk phos 119, AST 62, ALT 67, total bil 1.3, CXR-hiatal hernia, no acute, UA-negative. I also did a head CT and a spinal tap. CSF was normal. I gave Vancomycin, rocephin 2 gm, and acyclovir IVPB. He was intubated, foley, NG, and fluids continued. He was flown to Toledo before I had the CT results back. I wasn't sure what the source was, but I figured it was either in the brain or the belly, given his clinical presentation vs. his complaint of pain.

Because of the abdominal pain history, I also did a CT without contrast.
1. Distended gallbladder with irregular wall thickening and
pericholecystic inflammation. There is no evidence of dense
gallstones, but this is concerning for acalculus cholecystitis. If
desired, this could be further evaluated with HIDA scan or ultrasound.
2. No evidence of obstructive uropathy.
3. Moderate hiatal hernia. Distal tip of an enteric tube is seen
within the herniated portion of the stomach. There are a few foci of
gas along the periphery of the herniated stomach, which are most
likely within gastric folds. Possibility of extraluminal gas is
difficult to exclude. There is no evidence of pneumomediastinum
superior to this and no evidence of pneumoperitoneum, which makes
possibility of gastric perforation unlikely. Consider further
evaluation with an upper GI series.
4. Dependent bibasilar airspace consolidation, most likely
representing atelectasis.
5. Mildly thickened adrenal glands, possibly due to small adenomas.
6. Mild prostatomegaly.
7. Foley catheter in place

[jpollock]

This sounds like that type of case where you know he's really sick, but its tough to sort it out. good thing you got the rectal temp otherwise you may have anchored on a cardiac rabbit trail! wonder if there is a blockage in the bile duct? At least traditionally acalculous cholecystitis is something found in ICU/ hospitalized patients. HIDA/ ultrasound should be interesting.

[Bjs04f]

107 is reaching the level beyond where Id believe infection, I thought at that height were thinking malignant hyperthermia from med issues or heat stroke. the acalc chole fits with an overwhelming infection though. So urine, lungs, abd, csf not the source. leaves not much else unless he had a septic joint, decub ulcer. Any chance hes had a recent procedure, homeopathic meds etc. Or did he end up being infection unknown and septic

[erinto]

He ended up with a perforated gallbladder and intraabominal abscess, diagnosed at Toledo, underwent an open chole and abscess drainage. His blood cultures from Fostoria grew out E. Coli and Faecalis, the CSF, urine, and CXR were normal. So, truly septic. (I did consider the malignant hyperthermia route, but he had no risk factors for it, so I didn't think so. It was a good thought.) His meds were truly just a statin and anti-hypertensive. He did well post op, although was in house for 10 full days. He was sent to the ECF for rehab, but it was felt he would be able to make a full recovery.

No procedures, no homeopathics, no history of malignant hyperthermia, no psych meds, no travel.   No previous GB issues, per family.    They were shocked he was so sick...his wife acted like he had just a mild upset stomach.  

(I saw a 108 fever once on a child with a congenital brain malformation who had frequent fevers due to some type of central temperature control issue. Mom was well-informed, which helped. He was terminal, and eventually died.)

[erinto]

On another note-I have had two strep pneumo meningitis patients, both similar to this. Obtunded/lethargic with high fevers. The mortality is 50%, and if you miss it...ugh. I was lucky and mine both survived. I think I would have still tapped this guy, even with the CT results as above. CSF was clear and colorless, which made me feel better. Both strep pneumo taps looked like skim milk. Moral of the story-resuscitate and give antibiotics asap.