Internal Medicine Case Challenge: Hallucinations, Moaning, and Confusion in an 88-Year-Old

Danny Gersowsky, DO


May 10, 2023

Physical Examination and Workup

Upon examination, the patient is alert to person occasionally, appears to have intermittent hallucinations, and moans sporadically. Her vital signs include a heart rate of 124 beats/min, a respiration rate of 34 breaths/min, an oxygen saturation of 93% on room air, a blood pressure of 83/58 mm Hg, and a temperature of 99.4 °F (37.4 °C).

Results of the cardiac examination are consistent with tachycardia. The heart rhythm is regular, and S1 and S2 are normal. Breath sounds are diminished bilaterally. Her abdomen is not distended and is not tender to palpation in any quadrant. The neurologic examination shows no focal deficits, and cranial nerves II-XII are grossly intact.

Swelling of the left lower extremity calf, with mild tenderness, is noted. Further skin examination reveals a left buttock sacral decubitus ulcer, which is erythematous with foul-smelling discharge. Figure 1 shows a decubitus ulcer in another patient.

Figure 1.

Laboratory investigations reveal these values:

  • Hemoglobin level: 14.5 g/dL (reference range, 11.6-15 g/dL)

  • White blood cell count: 23 × 109/L (reference range, 4.5-11.0 × 109/L)

  • Creatinine level: 3.23 mg/dL (reference range, 0.74-1.35 mg/dL)

  • Blood urea nitrogen level: 89 mg/dL (reference range, 6-24 mg/dL)

  • Albumin level: 2.9 g/dL (reference range, 3.5-5.5 g/dL)

  • Calcium level: 18.1 mg/dL (reference range, 9-10.5 mg/dL)

  • Lactic acid level: 6.6 mmol/L (reference range, 0.5-2.2 mmol/L)

  • Troponin level: 1166 ng/L (reference range, < 14 ng/L)

A review of the patient's chart from her previous admission shows that her baseline creatinine level is 0.64 mg/dL and her previous documented calcium level is 12.9 mg/dL.

An ECG reveals no evidence of ischemia. A similar ECG in a different patient is shown in Figure 2.

Figure 2.

Duplex ultrasonography shows extensive left lower extremity deep venous thrombosis (DVT) in the left external iliac vein, left common femoral vein, left superficial femoral vein, and left popliteal vein. The ultrasound scans in Figure 3 reveal DVT in the right superficial femoral vein of another patient.

Figure 3.

CT angiography of the chest shows a thrombus in right lower lobe pulmonary artery, which is consistent with pulmonary embolism. No right ventricular strain is noted.


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