MDM:

– ED Course:

  – Diagnostically:

  – Complete Laboratory Analysis:

  – CBC:

  – No luekocytosis, no unexpected anemia, no thrombocytopenia.

  – BMP:

  – No significant pathologic electrolyte derangements.

  – LFTs/lipase:

  – No laboratory evidence of hepato-biliiary pathology.

  – UA:

  – No consistent with urinary tract infection

  – in conjunction with clinical context.

  – EKG Interpretation:

  – Normal EKG (Indication: eval for ischemia):

  – EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.

  – Interpretation: No clear evidence of active ischemia on EKG

  – Normal EKG (Eval for arrhythmia/syncope):

  – EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.

  – Interpretation: No cardiogenic etiology for syncope obvious on EKG.

  – Radiograph Interpretation:

  – CXR

  – Normal CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax.

– Differential Diagnoses:

Given limited history and high risk of morbidity and mortality with altered level of consciousness, broad differential considered.

Considered the following and the etiologies:

Hypoxic episode with subsequent encephalopathy

Infection

Encephalitis/meningitis

Encephalopathy secondary to bacteremia, pneumonia, urinary tract infection, intra-abdominal infection

Metabolic including hypoglycemia, uremia

Toxicologic specifically overdose of opioids, benzodiazepines, or other CNS depressants (both polypharmacy and street drugs), serotonin syndrome,

Significant CVA with bihemispheric ischemia

Trauma

Seizure with postictal status

Delerium, dementia

Diagnostically:

Point of care glucose

Broad labs including the following: CBC, BMP, LFTs, urinary analysis, serum acetaminophen, serum salicylate.

Radiographs including the following: Chest x-ray, CT head, CT neck, CT chest, CT abdomen and pelvis

lumbar puncture

– Medical Decision Making:

History does not suggest that patient had seizure with postictal status however cannot rule out and patient will remain monitored for improvement in mental status with supportive care.

Unlikely hypoglycemia given point-of-care glucose sources in within normal limits per paramedics and normal glucose here in the emergency department

Unlikely hypoxia given patient was evaluated and oxygenated adequately in the emergency department without improvement of mental status. It is possible that patient had previous episode of hypoxia which resulted in diffuse cerebral hypoxia.

Unlikely significant metabolic derangement given no gross abnormalities on basic metabolic panel

Unlikely significant CVA given patient does not have significant history suggestive of thrombi or source for emboli and would require a lesion to be central or bihemispheric which is a rare entity.

Unlikely traumatic in etiology given CT of head does not show any intracranial traumatic pathology

Unlikely dementia given his history suggests hyperacute onset

Suspect most likely altered level of consciousness of unclear etiology at this time. Aggressive supportive care provided by virtue of intubation as indicated for airway protection.

Plan for admission with continued observation. Further diagnostics may be indicated if patient does not improve in level of consciousness. If patient’s level of consciousness improves, patient may be able to be subsequently extubated and provide history revealing of events preceding presentation to the emergency department

Diagnosis: ALOC

Disposition: Admitted to ICU