“Saved by The Probe”
By Kaitlyn Florini PA-S and Patrick Bafuma PA-C
Kaitlyn is a second year PA student at Albany Medical College, Patrick is a PA-C and student preceptor in the Emergency Department and the creator of EM in Focus.
The presentation of a patient with altered mental status to the emergency department begins a long list of possible differentials which must be investigated and ruled out. The sooner the differential can be narrowed down; the sooner the patient is able to receive the appropriate care. As Coretellaro et al demonstrated, with the aide of Point-of-Care-Ultrasound (POCUS), the final diagnosis of septic source had a sensitivity of 73 % and specificity of 95%, with an accuracy of 75%; while the diagnosis of septic sources based only on clinical impressions without POCUS showed a sensitivity of 48%, specificity of 86%, and an accuracy of 52.5%. In this study, POCUS-implemented diagnoses were always obtained within 10 minutes while non-POCUS guided clinical impression identified a source within an hour only 22% of the time and 53% of the time within 3 hours.
Here, we present a case demonstrating the value of POCUS in the setting of an undifferentiated altered patient in the emergency department.
A patient in their mid 60's presents to the emergency department with a chief complaint of altered mental status for the past three days, which was accompanied by melena. A majority of the interview was conducted with the patient's significant other due to the patient’s altered mentation. The partner states that over the past three days the patient has been confused and forgetful. The partner became more concerned when the patients confusion began to progress, since the patients baseline is alert and oriented. The partner also notes that the patient has had worsening dark black, loose stools over the past three days. The patient denies any abdominal pain, nausea, vomiting, fever, chills, trouble urinating, or rashes.
On physical examination the patient is lying in bed in no acute distress. They are responsive to verbal and tactile stimuli and is overall generally confused throughout the encounter. Abdominal exam indicated the presence of some mild abdominal distention but no tenderness, masses, or guarding during deep palpation were noted. Rectal examination revealed intact rectal tone and the presence of melena, which tested guaiac positive. On neurologic examination, the patient is not oriented to person, place, or time. Cranial nerves two through twelve are intact. The patient appears to have no difficulty with movement or motor activity; there is no nuchal rigidity present. The remainder of his physical examination was unremarkable.
A CBC, CMP, and lumbar puncture were completed, all unremarkable. A point of care ultrasound examination conducted at bedside, revealed the presence of free fluid throughout the abdomen. Specifically, an accumulation was noted within the hepatorenal recess. At this point the presumptive additional diagnosis of spontaneous bacterial peritonitis was made.
Initially, several etiologies for AMS were considered. A fingerstick blood glucose and stat head CT were normal, as well as a CBC, CMP, and lactic acid. A rectal temperature was obtained, revealing a temperature of 98.0 degrees Fahrenheit. Urinalysis and urine toxicology screen was obtained and came back unremarkable as well. The patient went on to have a lumbar puncture, which was unremarkable. Due to this patient's questionable abdominal distention, POCUS was performed on arrival, and the diagnosis, much like in the Corellaro study cited, was made within minutes of arrival. While this patient was an obvious admission for a GI bleed, his altered mental status could not have been explained without POCUS and without POCUS, the diagnosis and appropriate care for this patient would have been significantly delayed.
The patient went on to have a paracentesis performed, confirming our clinical suspicions. The question remains, would this ascites have been discovered without the use of point of care ultrasound? How much later, if at all, would this diagnosis have been made if not for POCUS? With the use of bedside ultrasound, much like Cortellaro et al, we were able to establish a working diagnosis faster, ultimately allowing for the more efficient and effective management and treatment of the patient.
Cortellaro F, Ferrari L, Molteni F, et al. Accuracy of point of care ultrasound to identify the source of infection in septic patinets: a prospective study. Intern Emerg Med. (2016);12(3): 371-378