Case 1
An 82-year-old man presented to the ED accompanied by his son, who stated that his father “had not been acting right” for the past 2 days. The patient was combative, yelling “Go away,” and was intermittently more confused than his baseline; he was also eating and drinking less than usual. He had a history of mild dementia, noninsulin-dependent diabetes, hypertension, and arthritis; there were no recent changes in his medication. The patient lived alone in an apartment across the hall from his son and had home healthcare aide 4 hours a day, 3 days a week. He was independent of activities of daily living (ADL), but needed help with shopping and cooking.
At presentation, the patient’s vital signs were: temperature, afebrile; heart rate (HR), 94 beats/minute; blood pressure (BP), 146/92 mm hg; respiratory rate (RR), 22 breaths/minute. Oxygen (O2) saturation was 96% on room air. A finger-stick glucose test was 103 mg/dL. He was hyperalert and agitated, and did not appear oriented to place or time. There were no focal neurological deficits; mucous membranes were mildly dry; and faint crackles were heard at the right base of the lungs. The patient was placed on a monitor in a curtained room in the ED, and was given 2 L O2 via nasal cannula, which improved O2 saturation to 99%. With his son present, an intravenous (IV) line was placed and blood was drawn. An electrocardiogram (ECG) showed a sinus rhythm without ischemic findings.
During evaluation, the patient continued to pull at the monitor lines and attempted to get off the stretcher. To calm his agitation, he was given haloperidol 2.5 mg and lorazepam 1 mg; 10 minutes after administration, he became sedated and difficult to arouse. His vital signs remained stable.
Laboratory analysis revealed a white blood cell count (WBC) of 12.5 K/uL, a negative troponin, a brain natriuretic peptide (BNP) of 80 pg/mL, and normal blood urea nitrogen (BUN) and creatinine levels. Urinalysis was negative for infection, but chest X-ray showed a right lower lobe infiltrate. Blood cultures were drawn, and the patient was continued on maintenance fluids and started on IV antibiotics to cover community-acquired pneumonia. He was admitted to the hospital for pneumonia and altered mental status.
As the patient’s sedative state was followed by periods of agitation, he was treated with additional haloperidol and lorazepam by the inpatient medical team, which resulted in further sedation. On hospital day 3, his urinary output decreased. He was given an IV bolus of 3 L normal saline over 6 hours, after which his mental status began to improve, and he was switched to oral antibiotics. His mental status returned to baseline and O2 saturation was 99% on room air. He was discharged home on hospital day 5 accompanied by his son.
Case 2
A 75-year-old man was brought to the ED with a 3-day history of worsening dyspnea on exertion, increased orthopnea, and increased bilateral lower extremity edema. He had a history of congestive heart failure (CHF), with an ejection fraction of 40%, and had been on 40 mg of furosemide daily at home; there were no recent changes to his medication. The patient was independent of ADL at baseline, living with his wife in a home with stairs.
His vital signs at presentation were: temperature, afebrile; HR, 86 beats/minute; BP, 160/90 mm hg; RR 30 breaths/minute; O2 saturation was 92% on room air. The patient had increased work of breathing and was speaking in four- to five-word sentences. Pulmonary examination revealed crackles half way up bilaterally. He also had 2+ pitting edema bilaterally in his lower extremities. He was otherwise alert and oriented.
On 4 L O2 via nasal cannula, the patient’s O2 saturation was 98%. Laboratory analysis revealed a BNP of 600 pg/mL, negative troponin, and normal creatinine level. Urinalysis was negative for evidence of infection. An ECG showed no changes, and chest X-ray revealed mild pulmonary congestion without an infiltrate. In the ED, an indwelling urinary catheter (IUC) was placed to monitor urinary output before the patient was given 40 mg of IV furosemide for diuresis. The patient was then admitted for management of exacerbation of CHF. As the medical team was preparing to discharge him on hospital day 2, his wife noticed that he was confused and not acting “like himself.” An investigation for causes of delirium included evaluation for infectious disease, which revealed an elevated WBC of 14.0 K/uL, stable creatinine; and urinalysis positive for bacteria, WBCs, leukocyte esterase, and nitrites. Since chest X-ray showed resolution of the vascular congestion, the patient no longer required supplemental O2.