Case 1:

You are on call for the general medicine service and you are called to the ER to see an 80-year-old female.   Her daughter states that she has had the flu.   The last two days she has refused to eat and this evening she appears more confused.

Her past medical history includes CHF, type II diabetes, and mild dementia.   Medications include lasix 20 mg per day, digoxin .125 mg per day, enalapril 2.5 mg per day and glipizide 2.5 mg per day.   She has no allergies.   You are unable to obtain a review of systems from the patient and her family history is noncontributory.   Her sugars (per daughter) have been elevated at 200-300 the last three days.

Physical examination includes the following vitals: temperature 35.6, respirations 34, and blood pressure 100/50.   She is awake, but moaning.   Her HEENT exam shows bilateral cataracts, but equal and reactive pupils. Her TM's are normal.   Her mouth is dry and she has an absent gag reflex. Her neck is supple without enlarged lymph nodes or enlargement of the thyroid.   Her neck veins are flat at 45E.   Her cardiac exam shows a regular rhythm.   The PMI is displaced laterally.   There is no murmur.   The breast examination is normal.   There are decreased breath sounds at the right base with crackles.   The abdomen is soft and scaphoid with hypoactive bowel sounds.   The extremities show 2+ edema with chronic venous stasis changes.   There is no cyanosis.   Her neurological exam is without focal deficits. The Folstein mini mental status examination score is 6.

Laboratories include the following:

       11

12> <250     60S/20B/10L/10M

       32

Normal elctrolytes, BUN 30, CR 1.3, glucose 280

Normal LFTs, normal UA

CXR shows a RLL infiltrate

Oxygen saturation is 87% on room air.