MSN5031: Differential Diagnosis and Collaborative Management in Acute Care

CASE STUDY #1

Chief Complaint

A 39-year-old male is brought to the emergency department (ED) by emergency medical

services (EMS) with confusion and decreased responsiveness

General Survey and History of Present Illness (HPI)

In the preliminary evaluation of the patient, EMS personnel are still in the ED, and where asked

about the patient’s surroundings when they arrived at the scene. They noted that he was found at

home sitting in a chair and his brother was present. He had not been incontinent and there was

no evidence that he had fallen or had a seizure. They also report that no prescription bottles

found in the home; however, there was a half –filled bottle of acetaminophen found in the

bathroom, as well as a couple bottles of over-the-counter (OTC) cold medicines. There was no

smell of alcohol but they did not look for any empty bottles. They asked the patient’s brother to

check the garbage for any empty alcohol containers.

Upon entering the exam room, the AG-ACNP notes that the patient is a well-developed adult

male who appears to be sleeping. He is arousable to light tactile stimulation, is oriented to

person only, has slurred speech, a moderate cough, and adequate air movement with clear breath

sounds. He moves all extremities slowly but his strength is equal bilaterally in both his upper

and lower extremities and his face is symmetric.

Although his skin is tan, it appears jaundiced and the scleras are icteric. He has no evidence of

injury to his head or upper body. Although he has been changed into a hospital gown, the ED

staff reports he has not been incontinent. His bedside monitor shows a sinus tachycardia at 105

beats per minute and a pulse oximetry reading of 96% on room air.

His brother and mother arrive in the ED and are able to provide additional information related to

history. The brother states, “When I talked to him this morning he was fine. I didn’t notice

anything strange. We were supposed to go to the gym together after work but he didn’t show up

there and didn’t answer his phone. That concerned me because he had been having trouble at

work recently and last month his divorce was finalized. When I got to his house, I found him

just sitting in a chair in his bedroom. He couldn’t look at me, and I’m not sure he even

recognized me. He didn’t remember anything about going to the gym. He was kind of slurring

his words and when he finally looked at me his eyes looked really funny, almost yellow.” He has

not traveled out of the country recently.

Past Medical History

He has hypertension, but is not currently on any medication; he had his appendix removed as a

teenager and surgery on his left ankle after breaking it playing softball. His ankle causes him a

lot of discomfort at times, especially with changes in the weather. Family denies a history of

liver disease.

Allergies

No known drug allergies; he does have seasonal allergies.

Social History

In college he drank heavily and smoked marijuana. Since that time he rarely drinks, he has no

other illicit drug use, and he has never smoked. He currently manages a convenience store but

has had financial problems related to the business for the last year. He was married for 18 years.

Although they separated 4 years ago, it was only last year that his wife filed for divorce. The

divorce was finalized a month prior to this admission.

Medications

The family is not aware of any regular medication use; however, he is not opposed to taking

over-the-counter-medications for colds, allergies, and pain.

Review of Systems (ROS)

Because of the patient’s current mental state, a ROS is unable to be completed. However, the

family is able to contribute that he had complained that he thought he was getting a cold.

Thinking back over the last few weeks, they confirm that it seemed he was more withdrawn and

may have had some depression which they attributed to his reaction to his divorce.

Physical Examination

Vital signs:

HR 102 bpm BP 126/72 mmHg RR 18 breaths per minute Temp 99.4 F orally

Bedside monitoring: pulse oximetry 96% on 2L via nasal cannula (NC), telemetry reveals sinus

tachycardia

Constitutional: well-developed adult male, who appears his stated age, lethargic in bed

HEENT: head normocephalic and atraumatic, pupils equal, round, reactive to light and accommodation

at 2mm, sclera icteric, ears, nose, and oropharynx unremarkable with good dentition, mucous

membranes pale and slightly jaundiced, but with no evidence of bleeding

Neck: supple with no nuchal rigidity, trachea appears to be midline, no appreciable thyromegaly, no

jugular vein distension (JVD), no lymphadenopathy

Cardiovascular: normal S1S2, no murmurs, gallop or rub appreciated, peripheral pulses palpable, no

peripheral edema

Pulmonary: symmetric chest expansion, no retractions or accessory muscle use, bilateral breath sounds

clear throughout all lung fields, cough intact with no sputum production

Gastrointestinal: abdomen soft, nondistended with no organomegaly or masses palpated, patient

grimaces to palpation of right upper quadrant (RUQ) but no other evidence of abdominal tenderness,

normoactive bowel sounds

Genitourinary: Foley catheter in place and draining dark yellow urine; normal male genitalia

Integumentary: color jaundiced, warm and dry, no visible marks, lesions, or tattoos, no petechiae or

spider angiomas

Neurological: arouseable to touch, does not respond to voice, speech slurred, does not follow

commands, oriented to person only, able to elicit asterixis in feet bilaterally, reflexes present bilaterally

Diagnostic Testing Results
The comprehensive metabolic panel shows the following abnormal values:

Lab Result Normal Range

Potassium 5.2 3.5–5 mmol / L

CO2 13 22-29 mmol/L

BUN 32 7-21 mg/dL

Creatinine 2.1 0.6-1.1 mg/dL

Total bilirubin 23 0.2-1.1 mg/dL

ALT 3627 11-41 U/L

AST 5623 12-40 U/L

Alkaline phosphate 326 40-115 U/L

PT 29.8 9.6-12.5 sec

INR 3.4 1

Ammonia 106 11-51 umol/L

Lactate (venous) 12.6 0.5-2.2 mmol/L

Urinalysis Unremarkable

Note:

The rest of his electrolytes and hemogram are within normal limits.

Case Study Questions

1. What are the pertinent positives from the information given?

2. What are the significant negatives from the information given?

3. Based on the information presented, provide 3 differential diagnosis?

4. Are there any other diagnostic testing you would order? Provide a rationale to justify.

5. Formulate a diagnosis and treatment plan. Include national guidelines to support your

plan.