Delirious, Incontinent 45-Year-Old Found Crawling on the Floor

Ryan J. Cole, MD; Christopher P. Holstege, MD


September 01, 2022

Physical Examination and Workup

Upon presentation, the patient is disheveled, smells of urine, has slurred speech, and is unable to provide coherent additional history. He is alert but oriented to person only. His initial vital signs include a blood pressure of 93/34 mm Hg, a heart rate of 124 beats/min, a respiration rate of 22 breaths/min, a transcutaneous oxygen saturation of 98%, and a rectal temperature of 100.6 °F (38.1 °C).

The examination is significant for: dry mucous membranes, tachycardia, lateral gaze nystagmus, resting tremor of his extremities that worsens with activity, inability to perform finger-to-nose testing, truncal ataxia with inability to walk, hyperreflexia, and six beats of bilateral ankle clonus.

Initial laboratory studies reveal these values:

  • White blood cell count: 17,000 cells/mm3 (reference range, 4500-11,000 cells/mm3)

  • Potassium level: 3.8 mEq/L (reference range, 3.5-5.0 mEq/L)

  • Sodium level: 124 mEq/L (reference range, 135-145 mEq/L)

  • Chloride level: 111 mEq/L (reference range, 98-106 mEq/L)

  • Serum bicarbonate level: 14 mEq/L (reference range, 21-28 mEq/L)

  • Creatinine level: 2.88 mg/dL (reference range, 0.8-1.5 mg/dL)

  • Blood urea nitrogen (BUN) level: 52 mg/dL (reference range, 9-20 mg/dL)

  • Glucose level: 155 mg/dL (reference range [fasting], 74-106 mg/dL)

  • Calcium level: 8.8 mg/dL (reference range, 8-10 mg/dL)

  • Lactate level: 3.2 mg/dL (reference range, 0.5-1 mg/dL)

  • Thyroid-stimulating hormone (TSH) level: 1.41 mIU/L (reference range, 0.4-4.0 mIU/L)

  • Lithium level: 2.4 mEq/L (reference range, 0.6-1.2 mEq/L)

A urine drug screen is negative, and his urine specific gravity is < 1.010, with ketones detected. A head CT is normal. The only significant finding on the ECG is sinus tachycardia. The patient is admitted to a monitored bed. His urine output is 6.5 L during the first 24 hours of admission despite fluid restrictions.


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