Patient presenting with altered mental status August 28th, 2013 Thaer Ahmad M4 Contributing Resident: Dr. Urvi Tallor

CC: 62 year old male who presents with altered mental status. Clinical History CC: 62 year old male who presents with altered mental status. Patient is presenting with worsening confusion & somnolence. PMH includes Hepatocellular carcinoma, Hepatitis B, Cirrhosis, Diabetes, and HTN. Patient recently discharged for similar presentation; found to be secondary to hepatic encephalopathy and was discharged on Lactulose. Current concern for infection precipitating altered mental status. MRN: 6018231

Vitals: BP: 117/73 mmHg Pulse: 76 Temp: 97.9F Resp: 12 SpO2: 98 % H&P Continued Vitals: BP: 117/73 mmHg Pulse: 76 Temp: 97.9F Resp: 12 SpO2: 98 % Physical exam is within normal limits Lungs are clear to auscultation bilaterally Patient o btunded and unable to answer questions relevant to history and current presentation

Spontaneous Bacterial Peritonitis Pharyngitis Differential Diagnosis Pneumonia Spontaneous Bacterial Peritonitis Pharyngitis Essentially any infection given low immunocompetence of patient. 4

Paracentesis: <250 WBC count Relevant Labs WBC: 5.16 Hgb: 10.2 Hct: 29.2 PLT: 71 Glucose: 167 PT: 13.3 PTT: 30.0 INR: 1.25 Paracentesis: <250 WBC count 5

CXR ordered to investigate possible infectious etiology What should we do next? CXR ordered to investigate possible infectious etiology 6

Is CXR the appropriate diagnostic test? 7

Chest X-Ray Supine Frontal view (Portable)

Closer Look…. Left lower lung base opacity

New Differential -Pneumonia (#1) -Atelectasis (#2) -Pulmonary Edema -Pulmonary hemorrhage Additional Imaging? -AP/Lateral X-ray to further investigate consolidation. 10

Treatment and Outcome -Patient admitted and treated for possible pneumonia. Given IV antibiotics (Levofloxacin 500mg once daily) -Patient also given lactulose -Patient’s mental status improves -Patient is asymptomatic, afebrile, and reporting improvement. -New Chest X-ray ordered -Patient being evaluated for liver transplant 11

Chest X-ray, upright, AP/Lateral, Frontal view

Chest X-ray, upright, AP/Lateral, Lateral view

Comparison Resolved After Antibiotic Tx Possible Pneumonia Patchy Density

Discussion Clinicians arrive at the diagnosis of pneumonia by incorporating clinical judgment, radiological imaging, and diagnostic labs Presence of an infiltrate on plain chest radiograph is the gold standard for diagnosing pneumonia For hospitalized patients with suspected pneumonia and a negative chest radiograph, the 2007 IDSA/ATS consensus guidelines consider it reasonable to initiate empiric presumptive antibiotic therapy and repeat the chest radiograph in 24 to 48 hours CT scanning is not generally recommended for routine use because the data for its use in pneumonia is limited, the cost is high, and there is no evidence that it improves outcome

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