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Clinical Problem Solving 1

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Clinical Problem Solving 1

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    1. Clinical Problem Solving 1/13/09 Moderator: Stuart Cohen MD Discussant: Bill Curry MD

    2. Case #1 53 y/o white female presents to ED with several week h/o progressive mental status decline h/o well compensated cirrhosis due to past alcohol (none in 7 yrs), mild short term memory loss and diarrhea predominant IBS Now with difficulty finding words and unable to speak Agitation, weakness and lightheadedness

    3. Case #1 Seen in ED 5 days PTA with c/o shortness of breath, dizziness, weakness and memory loss Workup including head CT, chest x-ray, urinalysis, electrolytes, Liver function tests, Ammonia level was unrevealing and pt discharged home Progressive decline leading to ED visit After checking in but prior to being seen, pt loses consciousness and has witnessed tonic-clinic activity (in waiting room)

    4. Case #1 PMH: Alcoholic Cirrhosis (well compensted) Esophageal varices (s/p banding) COPD IBS (diarrhea predominant) Short term memory loss (? Secondary to cirrhosis) Depression MEDS Nadolol, lasix, aldactone, protonix, zoloft, ambien Recently prescribed compazine for nausea

    5. Physical Exam T: 101.5, HR: 50, BP: 70/palp, RR: 26 HEENT: cyanotic lips, PERRL, No gag reflex, Doll’s eye reflex absent CV: bradycardic but regular, NO murmurs, rubs Lungs: CTA, no wheezes, crackles ABD: S/ND/pos BS/ No HSM Ext: NO C/C/E Neuro: Unconscious, responds to painful stimulus, increased tone, DTR 3+ throughout with bilateral down going toes

    6. Data WBC 12 (31 segs/64 lymphs/3 monos) HCT 39, Plt 172 134 108 7 92 3.5 21 1 AST 27, ALT 11, Bili 1.0, Alk phos 82 Ammonia 29, CK 101, LDH 165 UDS: negative, ETOH: negative CSF: RBC 3, WBC 3, glucose 59, protein 44, VDRL neg, CSF : HSV ,West Nile, Crypto, bacterial cultures all negative CXR- No infiltrate, no pulmonary edema Blood, Urine cultures- Negative

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