WBR0220

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Endocrine, SubCategory::Neurology, SubCategory::Endocrine, SubCategory::Neurology
Prompt	[[Prompt::A 76 year old female is admitted to the hospital because of altered mental status. She has a history of diabetes, hypertension, osteoporosis and mild depression. At home, she was on metoprolol, rosiglitazone, hydrochlorthiazide and sertaline. She also takes alendronate on a weekly basis. She has been on these medications for a number of years. Before admission, she was living independently in her apartment and was able to perform nearly all day-to-day activities. It was her daughter who found her in her apartment, very confused in her bed. On examniation, you see a drowsy, frail, elderly women in no acute distress. Her temperature is 36.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiartions are 16/min. Her oxygen saturation is 97% on room air. The neck is supple without any jugular venous distension or thyroid enlargement. The oropharynx is dry. Pupillary reflexes are intact. There is no obvious pallor or icterus. Lungs are clear to auscultation. Cardiovascular and gastrointestinal systems are unremarkable. On neurological examination, the patient is not very cooperative. She knows her name but disoriented to time and place. She can move all her extremities. Touch sensation are intact and deep tendon reflexes are symmetrical. On lab investigations, total and differential white count is normal. Her Hemoglobin and hematocrit are 12.3 g/dl and 36.5 respectively. Serum biochemistry shows Na:135 mEq/L, K : 3.6 mEq/L, Cl: 104mEq/L, Bi: 24 mEq/L, BUN: 30 mg/dl, glucose: 72 mg/dl and Ca: 10mg/dl. A CT scan of the head performed in the emergency department shows generalized cerebral atrophy. What is the most appropriate next step in the management of this patient?]]
Answer A	AnswerA::Discontinue rosiglitazone
Answer A Explanation	[[AnswerAExp::Incorrect : Rosiglitazone acts by improving insulin sensitivity and does not usually causes hypoglycemia like sulfonyureas.]]
Answer B	AnswerB::Discontinue hydrochlorthiazide
Answer B Explanation	[[AnswerBExp::Incorrect : Thaizide can cause altered mental status by decreasing sodium and sometimes by increasing calcium levels. However the metabolic panel is normal and hence thiazide is not responsible for altered mental status.]]
Answer C	AnswerC::Perform a lumbar puncture.
Answer C Explanation	[[AnswerCExp::Incorrect : The patient has no fever, headache, neck rigidity (classical symptoms of meningitis) and therefore lumbar puncture should not be present as the next step]]
Answer D	AnswerD::Order thyroid function tests.
Answer D Explanation	AnswerDExp::'''Correct''' : Apathetic thyrotoxicosis is an atypical though not rare manifestation of hyperthyroidism that requires high level of suspicion and could be ruled out through thyroid function tests.
Answer E	AnswerE::Discontinue sertaline.
Answer E Explanation	[[AnswerEExp::Incorrect : Potentially life-threatening serotonin syndrome (SS) has occurred with serotonergic agents (eg, SSRIs, SNRIs), particularly when used in combination with other serotonergic agents (eg, triptans, TCAs, fentanyl, lithium, tramadol, buspirone) or agents that impair metabolism of serotonin (eg, MOA inhibitors like linezolid and intravenous methylene blue). Monitor patients closely for signs of SS such as mental status changes (eg, agitation, hallucinations, delirium, coma); autonomic instability (eg, tachycardia, labile blood pressure, diaphoresis); neuromuscular changes (eg, tremor, rigidity, myoclonus); GI symptoms (eg, nausea, vomiting, diarrhea); and/or seizures. Discontinue treatment (and any concomitant serotonergic agent) immediately if signs/symptoms arise. Sertaline can also cause SIADH and hence symptoms like altered mental status because of hyponatremia.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::The most common causes of altered mental status in elderly are medications, metabolic abnormalities (Hypo or hypernatremia, hypoglycemia and infections like UTI and pneumonia). Apathetic thyrotoxicosis is an atypical though not rare manifestation of hyperthyroidism that requires high level of suspicion. The cardinal features are apathy and depression, as opposed to hyperkinesis and mental alertness in the usual thyrotoxic patient. This is unassociated with the usual signs and symptoms of hyperthyroidism, making the diagnosis difficult. Medical treatment not only restores normal behavioral activity but also results in a loss of wrinkles and a more youthful physical appearance. Untreated, the patient is likely to succumb to the effects of stress or acute illness. This patient may have this condition and hence it has to ruled out with thyroid function tests. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::