Pile Justin E, Truong Justina
Swedish Hospital, Northshore University HealthSystem, Department of Emergency Medicine, Chicago, Illinois.
Kingman Regional Medical Center, Department of Emergency Medicine, Kingman, Arizona.
Clin Pract Cases Emerg Med. 2021 Nov;5(4):502-506. doi: 10.5811/cpcem.2021.3.51331.
The differential diagnosis for altered mental status and respiratory failure is broad. Careful physical examination, appropriate use of diagnostic tools, and accurate interpretation and correlation of test results are important for piecing together the puzzle of a patient with altered mental status that emergency physicians commonly face. In certain cases, such as this one, rapid diagnosis and management is crucial for improving patient morbidity and mortality.
A 48-year-old male with altered mental status and respiratory failure presented to the emergency department after being found unconscious on his porch. Vital signs were notable for temperature 105.5 °F, blood pressure 202/102 millimeters of mercury, pulse 126 beats per minute, respiratory rate 30 breaths per minute, and oxygen saturation 91% on room air. Physical examination revealed an obese male lying in bed awake in severe distress with labored breathing and unable to converse. His physical examination was significant for dry mucous membranes, tachycardia, and bilateral lower extremity 1+ pitting edema. He also appeared to have Kussmaul respirations with severe tachypnea, but his breath sounds were clear to auscultation bilaterally. On further examination, the patient appeared to have intravenous (IV) injection markings along his arms suggesting the possibility of IV drug use.
With limited history, the only context clues initially available to assist in the diagnosis were abnormal vital signs and physical examination. The patient was tachycardic, hyperthermic, hypertensive, hypoxic, and tachypneic with altered mental status; he eventually required endotracheal intubation for hypoxic respiratory failure. The complexity of his condition prompted a large list for the differential diagnoses. Toxidromes, endocrine abnormalities, infectious process, cardiac and/or renal etiologies, and neurological pathology such as a cerebrovascular accident were considered. In the case of this patient, urgent diagnosis and management was crucial to prevent further decompensation and improve his outcome.
精神状态改变和呼吸衰竭的鉴别诊断范围广泛。仔细的体格检查、诊断工具的恰当使用以及对检查结果的准确解读和关联，对于拼凑急诊医生常见的精神状态改变患者的病情谜团至关重要。在某些情况下，如此病例，快速诊断和处理对于改善患者的发病率和死亡率至关重要。
一名48岁男性，精神状态改变且呼吸衰竭，在门廊被发现昏迷后被送往急诊科。生命体征显示体温105.5°F，血压202/102毫米汞柱，脉搏126次/分钟，呼吸频率30次/分钟，室内空气中氧饱和度91%。体格检查发现一名肥胖男性躺在床上，清醒但极度痛苦，呼吸费力且无法交谈。体格检查的重要发现包括黏膜干燥、心动过速以及双侧下肢1+凹陷性水肿。他还表现出库斯莫尔呼吸伴严重呼吸急促，但双侧听诊呼吸音清晰。进一步检查发现患者手臂上有静脉注射痕迹，提示有静脉吸毒的可能性。
由于病史有限，最初可用于辅助诊断的唯一背景线索是异常的生命体征和体格检查。患者心动过速、体温过高、高血压、低氧血症、呼吸急促且精神状态改变；最终因低氧性呼吸衰竭需要气管插管。其病情的复杂性导致了一长串的鉴别诊断。考虑了中毒综合征、内分泌异常、感染性疾病、心脏和/或肾脏病因以及诸如脑血管意外等神经病理学情况。对于该患者而言，紧急诊断和处理对于防止进一步失代偿和改善其预后至关重要。
