EM Forum Case #113 "Weak and Dizzy!"
by Charlene Babcock Irvin, MD, FACEP  

An 82 y/o female is brought in by her family with the chief complaint of weakness. She has a history of recurrent urinary tract infections. She denies any chest pain, shortness of breath, abdominal pain, fevers, nausea, vomiting, or cough. No back pain. Urine does smell ‘strong’.

Her son provides more information and tells you that she has had a lot less energy over the past 2 days. She has lost her appetite, and today didn’t even want to get out of bed.

When I ask her why she didn’t want to get out of bed, she says, “I’m just to weak!”

PMH: Dementia, Hypertension, and Type II Diabetes.

SH: Lives with her son’s family, normally ambulatory.

Medications: Diabeta, Metoprolol, Arecept, and a baby aspirin daily.

PE: WD Thin elderly female, in no acute distress, with good eye contact.

VS: 110/50, HR=70, RR=20, Temp = 98F, Sat 98% on RA

HEENT: Unremarkable, neck supple

HEART: Normal, no Murmur

Lungs: Clear bilaterally, normal.

Abd: Soft, non-tender. No AAA palpated.

Back: No CVA tenderness

Rectal: Brown stool, guiac positive

Ext: No rashes, normal, pulses symmetric

Neurologic: Normal motor, sensory, reflex, Cranial Nerve, mental status and cerebellar testing.

Her work up reveals:
EKG: Normal, unchanged
Lytes, BUN CR, Glu: all normal
CBC: WBC=9,000, HBG=14.4
Cardiac enzymes: Normal
Urinalysis: SG: 1.020, 15 WBC, 5 RBC, Squamous Epi=2, Trace +Nitrate

Your senior resident wants to treat her for her UTI and send her home. She has a reliable family, and can follow up with her doctor in the AM.

Questions:

1. “What about her Guiac positive stools?” you ask the resident. The resident notes her HBG is stable, and her vital signs are normal. Are they?

2. When you ask her how she feels, she tells you she still feels very weak. Should you send her home?

3. What is the mortality rate if she does have a bleeding ulcer?

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