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

2. 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:

3. 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

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

5. 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

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

7. Is CXR the appropriate diagnostic test?7

8. Chest X-Ray Supine Frontal view (Portable)

9. Closer Look….
Left lower lung base opacity

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

11. 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

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

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

14. Comparison
Resolved After Antibiotic Tx
Possible Pneumonia
Patchy Density

15. 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

16. Thanks for listening