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  #1  
Old 09-07-2012
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A 79-year-old man presents to the ED by paramedics with the chief
complaint of agitation and confusion over the previous 12 hours. He has a past medical history of schizophrenia and is not taking any of his antipsychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?

a. Administer haloperidol or lorazepam
b. Consult psychiatry
c. Order a CT scan of his head
d. Send a urine toxicologic screen
e. Obtain a rectal temperature
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Old 09-07-2012
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ans D looks like the old man had a taste of phencyclidine .......
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c. Order a CT scan of his head
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Old 09-07-2012
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Quote:
Originally Posted by step_enhancer View Post
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A 79-year-old man presents to the ED by paramedics with the chief
complaint of agitation and confusion over the previous 12 hours. He has a past medical history of schizophrenia and is not taking any of his antipsychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?

a. Administer haloperidol or lorazepam
b. Consult psychiatry
c. Order a CT scan of his head
d. Send a urine toxicologic screen
e. Obtain a rectal temperature

D. Toxicology screening...Possily cocaine toxicity
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Old 09-08-2012
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Quote:
Originally Posted by step_enhancer View Post
Not from Qbank

A 79-year-old man presents to the ED by paramedics with the chief
complaint of agitation and confusion over the previous 12 hours. He has a past medical history of schizophrenia and is not taking any of his antipsychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?

a. Administer haloperidol or lorazepam
b. Consult psychiatry
c. Order a CT scan of his head
d. Send a urine toxicologic screen
e. Obtain a rectal temperature

A.) give haloperidol.
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Old 09-08-2012
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D)...toxo screen
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A ....would have been a viable option because haloperidol is used to treat agitation in elderly but adding lorazepam makes the option invalid...

B....not to be considered


C..no focal neurological signs...pupils normal...so invalid too

D...urine toxicology seems viable too...but for his age would not go for that...

E...he could have an occult infection causing his confusion and agitation


So E....would be my best option
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Old 09-08-2012
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E, judging by his age and comorbidities i think he has an occult infection

Only 3 things can give acute settings: infections, strokes or toxicology
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Old 09-08-2012
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Very Nice stfidel & XpaezX ,you are correct ,nice thinking

The answer is E. Patients frequently present to the ED with agitation. It is important to discern what is causing their agitation; the range of etiologies is expansive, from ethanol intoxication to intracerebral bleeding. The approach to the emergency patient always begins with the ABCs (airway, breathing, and circulation). In addition, the vital signs must be obtained early in a patient’s assessment inorder to reveal potentially life-threatening conditions. The patient inthe vignette presents with agitation and tachycardia. Although it is tempting to attribute his agitation to his untreated schizophrenia, doing this without investigating medical causes of agitation can be disastrous. Finding out that the patient’s temperature is 103.1F, for instance, will lead you down a different clinical path than if his temperature is 98F. This patient was ultimately diagnosed with meningitis.
(a) Administering a medication to control agitation or psychotic behavior is appropriate even when there are coexistent medical problems. Patients that are too agitated cannot be properly examined. However, it is critical to rule out potential life threats that may be causing the agitation. (b) A psychiatry consultation should be obtained once life-threatening conditions are excluded or in the case of the patient above, when he is stable and communicative as an inpatient. (c and d) A head CT and blood work will need to be obtained in this patient; however, all of the vital signs should be obtained first.

The Question tricked us by not providing Vital signs ,we are use to reading Temperature in the Vineate.Sometime they might skip it and it may be very important as in this case.
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Last edited by step_enhancer; 09-08-2012 at 06:51 AM.
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