St. Luke's – Roosevelt Emergency Department

Medical Student Elective

HPI
A 78 year-old female with presenting complaints of weak, dizzy and abdominal pain. The symptoms were associated with nausea and vomiting multiple times in the last 24 hours. As per her daughter, the patients was not herself, was weak, less alert and more agitated. The patient had no PO intake today, had not taken her medications and was having no bowel movements or obvious passage of gas, but had been urinating normally. No fever or chills. Her daughter reported an unwitnessed fall this morning with no LOC although she did hit her head on the floor. No complaints of headache now.


PMH
Hypertension, stroke 06 (without major complications), surgery related to ulcer many years ago, asthma, osteoporosis.


PE (pertinent)
Vitals: BP: 202/79, PR: 64, RR; 16, Sat: 95%, Temp: 97.6.
Constitutional: Weak, uncooperative/agitated, ill appearing.
Head: Right temporal scalp hematoma.
Cardiovascular: Regular rate and rhythm, systolic murmur 2/6.
Respiratory: Clear to auscultation, no rales, rhonchi or wheezing.
GI: Soft, non distended, no guarding or rebound, normal bowel sounds, mild epigastric tenderness.
Dermatologic: Mucosal membranes dry, poor skin turgor.
Neuro exam: Pupils reacting normally. Motor intact in all 4 extremities, AOx1, slow speech. Pt felt too weak to stand for gait evaluation.

EKG
Rate 70/min, sinus rhythm. LVH. T inversions in I, AVL, V5, biphasic III, V1-V4. Wide QRS. Findings new compared to previous EKG.


LABS
CBC: WBC – 19.6K/uL. Metabolic: Sodium 136mmol/L, Chloride 93mmol/L, K+ 3.9, normal Creatinine, ALT, AST, CO2, Anion gap. Normal Lactic Acid, Lipase, INR and PT. Trop 0.038ng/mL.


Course
The patient was given IV fluids, Haldol and Zofran. A CXR was normal, and CT scan of her abdomen was performed (see Image 1).

Image 1 – No evidence of acute abdominal or pelvic process. No evidence of gastrointestinal obstruction.

CT of her head showed a cerebellar infarct with compression of the 4th ventricle, upward herniation and supratentorial hydrocephalus.

Image 2, 3 – Cerebellar infarct edema, compression of 4th ventricle, upward herniation through the tentorium and supratentorial hydrocephalus.

Awaiting Neurosurgical consultation the patient became somnolent and unarousable. She was intubated, given mannitol and transferred to Roosevelt Hospital for decompression by suboccipital craniotomy and C1 laminectomy. She was also given an External Ventricular Drainage (EVD) (see Image 4) to decrease the hydrocephalus.

Image 4

Image 5

Progress
The patient is now in Intensive Care Unit. She had the EVD removed after a week and the swelling has been followed by repeated CT scans (see Image 5). She had a tracheotomy placed along with a PEG, She is very tired and can’t mobilize herself but she can move all extremities and does respond to instructions. She is gaining strength and awaiting further rehabilitation.

Take home message
During Gastro season, it is very easy to ascribe all of her symptoms to a gastrointestinal cause and dehydration. It is always important to consider a broad differntial and concern for neurological causes of vomiting and altered mental staus. Had/she not fallen and had a small hematoma, it is possible that the brain CT may have been delayed or not ordered at all.

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Program Directors

Jennifer Stratton, MD and Jonathan Wassermann, MD
slredmedstuds@yahoo.com