Features of the Case unrelated to the Diagnosis have been changed for patient privacy
60 yo F Patient works in the IT department of Ford, recently retired
CC: ALTERED MENTAL STATUS
HPI: Patient went to work; clocked in at 7 AM on Feb 20, then clocked out at 7:30 AM, patient went to the car drove in the parking lot, then went back in clock in at 8 AM, then clocked at 8:30 AM went to her car and sat there. (Per security video footage) Patient remembers clocking in and out the first time but does not recall the second time.
Coworkers went looking for her, and had found her with her coat on, sitting in her car with it off and the windows up. They reported her saying ” I don’t feel like working” They state she was found diaphoretic . Patient reported losing bladder control between 8 AM and 8:30. She said that “I felt like I needed to go on I went.” Patient talked to her daughter and she sent an ambulance to find her in the parking lot.
Past Medical History
Past Medical History GERD with Barrett’s esophagus, HTN, Obesity
Surgical History Appendectomy, Cholecystectomy,
Family History Father: HTN, MI (@age 70) Dementia Mother: HTN,
Social History
Never smoker
Occasional Alcohol, 1-3 drinks/week
Denies Ever: THC, LSH, IV drugs, etc.
MEDS: Omeprazole 20 mg PO Daily
Physical Exam
Temperature: 98.8 Pulse: 91-107 Respiration: 17 BP: 188/85 on arrival, down to 123/61 Pulse Ox: 99 (RA)
Head: Normocephalic, atraumatic. CV: Reg rate, ryth. No LE edema. No JVD. Pulm: Lungs CTAB, no rhonchi, No inc work of breathing. Abd: Soft, non tender, non distended. Skin: No rashes, lesions or bruises.
Neuro:
| – Patient alert and oriented to person, place, time and situation. – Following simple and complex commands. – Naming and repetition intact – No aphasia | – EOM intact. PERRLA. No nystagmus. – Face symmetrical – Shoulder shrug equal – Tongue midline – No dysarthria | Motor: – RUE 5/5 – RLE 5/5 – LUE 5/5 – LLE 5/5 Sensation – Intact in all extremities Gait: No ataxia, |
Psych: Patient is not responding to internal stimuli. Mood is stable, appropriate, affect is somewhat flat. Good eye contact.
- What initial testing do you want?
- With the acuity of the patient’s complaint, which diagnoses will be ruled in or out with CT imaging?
- What are your top 3 differential diagnoses?
Diagnosis is not the end, but the Beginning of Practice
Martin Fischer
