Case 2 :

A seventy-three year old woman, Mrs. Walker, is brought into the emergency room by her daughter.   Her daughter had found her in her apartment unkempt, confused, and saying that people had broken in and stolen things.   Mrs. Walker's daughter had last spoken with her mother two days previously and became alarmed when she did not answer the phone earlier today.   Mrs. Walker had not felt well for the past two weeks with complaints of nausea, abdominal discomfort, and worsening of her chronic pain from osteoarthritis of the knees.

In the emergency room, Mrs. Walker does not answer questions appropriately and is unable to provide a coherent history.  

Mrs. Walker had been taking ibuprofen 600 mg, three times a day, for her knee pain.   A friend in her building suggested she try over-the-counter cimetidine for her abdominal discomfort.   Mrs. Walker takes no other medications.   She is allergic to penicillin, and develops hives as a reaction.

Social history is remarkable for a supportive family that lives in the surrounding community.   Mrs. Walker is normally active in her local church where she volunteers at the church-run day care center.   She has been independent in her activities of daily living and instrumental activities of daily living.   She does not smoke and has only a rare drink.   Mrs. Walker has been widowed for many years.  

Physical exam reveals a frightened, thin, older woman who is unkempt, picking at her hospital gown, and not cooperative with efforts to examine her.

Vital signs include a regular pulse of 120, blood pressure of 100/80, a temperature of 100.5 R, and a respiratory rate of 20.

Skin:    There are several bruises on her back and buttocks.

HEENT: Pupils equal and reactive, EOM's full, no blood behind tympanic membranes, oropharynx   appears very dry.

Neck:   Not cooperative with exam but no clear rigidity.

Lungs:  Bibasilar crackles.

Cardiac:Regular and rapid with no murmur or gallop.

Abdomen: + bowel sounds.   Diffusely tender to exam without rigidity.   No masses or organomegaly.   Rectal exam reveals black, guaiac positive stool.

Extremities: Bony deformity and swelling of both knees without erythema or warmth.

Neuro: Speech is fluent but confused.   Frightened that Athose men will get me.  Cranial nerves without gross deficit.   Moves all extremities well.   Sensory and cerebellar not checked.   Gait not checked.   Reflexes 3+ throughout.   Toes withdraw to plantar stimulation.

Folstein Mini-Mental State Exam:   Impossible to do secondary to inattention.   Unable to do serial sevens or spell “WORLD” backward.

Initial laboratory tests return as follows:

CBC   

Hgb 7.0, Hct 25
WBC 15,000 with 85P, 10Ly, 3Mo, 1Eo, 1Ba
Platelets 250,000

Electrolytes

Na+       153
K+          4.5
Cl-          112
C02        30

Renal function      

BUN 70
Cre 2.5
Glucose    180

Urine SG 1.020, + WBC, trace blood, micro with gram negative rods

ECG reveals sinus tachycardia with normal intervals, a poor baseline because of patient movement, non-specific ST and T wave changes, but no obvious signs of acute ischemia.

A nasogastric tube is dropped revealing only a few coffee grounds.