Cases june 27 for psychiatric module discussion

casE discussions psychiatric

1. Case #1 A 78-year-old man presented with a sudden onset of abdominal pain, vomiting and dyspnea. He had become unresponsive in ambulance and was intubated. History.  No further history of present illness could be obtained. The patient had no known drug allergies. He also had prostate cancer, hypertension, hyperlipidemia, and bilateral peripheral vascular disease. Family history of hypertension and hyperlipidemia/ The patient has a 30 pack-year history of smoking, but he had quit 3 years prior. He has 3 or 4 alcoholic drinks a week.

2. Physical examination.   Vital signs were as follows: blood pressure, 190/98 mm Hg; pulse, 136 beats/min; respiratory rate amb u bag every 6 secs, oxygen saturation, 88% on 15 L/min oxygen administered via bag valve mask. Cardiovascular and respiratory examination findings were unremarkable.

3. Diagnostic tests .  His white blood cell count was 9,980/µL, his hemoglobin level was 11 g/dL, and his platelet count was 238 × 10 3 /µL. The troponin I level was elevated at 0.06 ng/mL, and the B-type natriuretic peptide (BNP) level was 460 pg / mL. Electrocardiography (ECG) showed sinus tachycardia, left axis deviation, and left bundle branch block ( Figure 1 ). No previous ECG was available for comparison .

4. Bedside echocardiography is another diagnostic options to help in making a quick decision in a case for reperfusion therapy in these instances. The presence of wall-motion abnormalities revealed by bedside echocardiography supports the presence of a STEMI. This is a case of MI with atypical presentation, since we could not elicit the typical symptoms such as left-sided chest pain because the patient was obtunded. T he patient had dyspnea, risk factors for acute coronary syndrome (ACS), signs of fluid overload with bilateral opacity on chest radiographs, elevated troponin levels, and LBBB on ECG, all of which are highly suggestive of ACS.

5. Approximately 6.7% of patients with acute MI present with LBBB.  LBBB can interfere with ECG interpretation and the diagnosis of an acute MI when the age of the LBBB is unknown. One group of researchers noted that chest pain was not present in half of patients with LBBB and an acute MI.

6. Case #2 An 88 year old female with a history of hypertension, GERD, and gastritis presents with abdominal pain and fatigue for the past three days. Her abdominal pain is “everywhere” and does not feel more prominent in a specific region. She denies fever, but endorses chills and generalized weakness. She reports poor appetite over the past three days with persistent nausea but no vomiting or diarrhea. She has never had similar symptoms before and has no history of prior abdominal surgeries. Vital signs are as follows: HR 95, BP 98/53, T 97.5° F, RR 18, SpO2 99% on room air.

7. Physical Examination she appears uncomfortable. A bdomen is soft with diffuse mild abdominal tenderness to palpation but no rebound tenderness or guarding. The remainder of her examination is normal. 30 minutes after you have evaluated the patient, the nurse calls you to inform you that her blood pressure is now 80/49.

8. Initial evaluation infectious symptoms includes: Complete blood count with differential Complete metabolic panel Lipase Troponin Lactate Urine analysis Blood cultures ECG In older adults with chest pain, initial evaluation includes: STAT ECG Complete blood count with differential Basic metabolic panel Troponin Consider D-dimer based on risk stratification tools such as Wells score and clinical gestalt

9. CT scan of perforated diverticulitis with diverticula (thin arrows) and free abdominal air (thick arrows).

10.  Perforated sigmoid diverticulitis: sigmoid colon displaying diverticulosis and mural thickening (arrow) with adjacent collection of intra-abdominal free air and adjacent inflammatory fat stranding (circle), representing active diverticulitis with perforation. 

11. Physiologic changes of aging Medication effects Other factors Decreased pain and temperature perception Beta blockers or calcium channel blockers mask tachycardia Multiple comorbidities Decreased humoral and cell mediated immunity Chronic steroid use blunts immune response Dementia, delirium, or cognitive decline limits history Decreased response to pyrogens Chronic analgesics blunt pain perception Functional dependence or living in a care facility Decreased renal function Adverse effects of medications Limited social support

12. Case Resolution The patient is resuscitated with IV fluids with improvement in her blood pressure and broad spectrum antibiotics are initiated. Labs are notable for an elevated lactate of 6.0 mmol/L. STAT chest X-ray demonstrates free air under the diaphragm. Once the patient has been stabilized, a CT of the abdomen and pelvis is obtained that demonstrates perforated diverticulitis. General surgery is consulted and the patient is taken to the OR emergently. After her hospital admission, the patient is able to return to her assisted living facility with physical therapy support.

13. Initial Actions and Primary Survey Evaluation of older adults in the ED begins with evaluation of the ABCs. Evaluate the patient for signs of aspiration or airway obstruction, inadequate respirations, and poor perfusion which indicate critical illness. This helps to establish if the patient is “sick” or “not sick”.  Critically ill patients require rapid intervention before proceeding with the history. Initial actions include establishing IV access ( two large bore IVs if hemodynamically unstable ), administering supplemental O2 if hypoxic, and placing the patient on the monitor. Obtain a STAT point of care glucose in any patient with altered mental status, as hypoglycemia is a common cause of encephalopathy. A STAT ECG in a patient with vague symptoms or a patient who is ill appearing can indicate myocardial ischemia or arrhythmia.

14. Pearls and Pitfalls Critical illness often presents atypically in older adults: maintain a high index of suspicion for the critical pathology in the older adult with vague symptoms. Peritoneal signs are often absent in the geriatric acute abdomen due to decreased pain perception. Fever and leukocytosis are often absent in patients with acute infection due to immunosenescence .  A broad differential diagnosis is necessary in older adults due to lack of localizing symptoms. Acute coronary syndromes may present without chest pain, particularly in older adults and female patients.

15. Pearls and Pitfalls Check the patient’s medication list for beta blockers that blunt tachycardia or other medications that may mask symptoms. Obtain collateral history to guide next steps in management. Establish the patient’s goals of care. Have a low threshold for labs and CT imaging. In geriatric patients with acute abdominal pain, CT is the modality of choice.  Manage and treat pain when appropriate, while being mindful of dose and drug interactions.