Cases

Introduction

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 Cortellaro et al demonstrated, with the aid 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%. 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.

Case Presentation

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, 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, and became more concerned when the patient's confusion began to progress.

On physical examination the patient is lying in bed in no acute distress, responsive to verbal and tactile stimuli, and generally confused throughout the encounter. Abdominal exam indicated some mild abdominal distention but no tenderness, masses, or guarding during deep palpation. 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 with no difficulty in movement; no nuchal rigidity.

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, with an accumulation noted within the hepatorenal recess. The presumptive additional diagnosis of spontaneous bacterial peritonitis was made.

Discussion

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. Urinalysis and urine toxicology screen were unremarkable. The patient went on to have a lumbar puncture, which was also unremarkable. Due to this patient's questionable abdominal distention, POCUS was performed on arrival and the diagnosis was made within minutes. While this patient was an obvious admission for a GI bleed, his altered mental status could not have been explained without POCUS.

The patient went on to have a paracentesis performed, confirming the 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? With the use of bedside ultrasound, much like Cortellaro et al, a working diagnosis was established faster, allowing for more efficient and effective management and treatment.