She initially received extra PRN doses of the trazodone and haloperidol, but these were discontinued two days prior to presentation. When she was admitted to the Alzheimer’s facility, she suddenly started receiving all her medications. Our best guess is that the patient had not been taking her medications as prescribed while at home. Her trazodone and quetiapine had been titrated up during the previous month. The patient had been on a long-term, stable dose of citalopram. Serotonin syndrome likely from a combination of citalopram, trazodone, and quetiapine. Her mental status improved and 15 days later she was discharged at her mental baseline. Her citalopram, trazodone, quetiapine, citalopram, and divalproex were held, and the next day her rigidity had decreased, unmasking hyper-reflexia and induced clonus. The patient’s UTI was treated, but she clearly had another cause for the dramatic change in mental status and the increased motor tone. Her UA showed positive nitrites, positive leukocyte esterase, and 24 WBC/hpf. She did not have any clonus or hyper-reflexia, but she had markedly increased tone in her upper and lower extremities. She was lying in bed moaning, would not follow commands or answer questions, but was able to withdraw all 4 extremities to stimuli, and had no facial droop. She had also received extra doses of prn trazodone and haloperidol at the facility initially because of her increasing agitation and aggressive behavior but they were both then discontinued 2 days prior to presentation. The trazodone and quetiapine had been titrated up during the previous month. Her medications included trazodone, citalopram (Celexa), quetiapine (Seroquel), divalproex (Depakote), levothyroxine (Synthroid), simvastatin (Zocor), valsartan/HCTZ (Diovan), and haloperidol (Haldol). She was brought into the ED with severe mental status changes that had been worsening since she moved to the facility. When she had moved into the facility she was ambulatory and conversant with family members, with her baseline cognitive impairment, which involved moderate limitations in ADLs, and frequent hallucinations. She had a history of moderate to severe dementia and had been placed in an Alzheimer’s facility 4 days previously. This is a case of a 67-year-old woman with an unusual cause of altered mental status… and a UTI. I then banish the thought of a UTI and force myself to go through a worst-first differential diagnosis to exclude, either through the history and clinical assessment or through testing, more dangerous causes. What’s the first thing that pops into your head when you see an older woman presenting to the ED from a nursing facility with atraumatic altered mental status? If you’re like me, ‘UTI’ comes quickly to mind.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |