Case #90 "Hot and Hyper"
by Charlene Babcock Irvin, MD, FACEP
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A 42 y/o female presented by EMS with the
chief complaint of Change in Mental Status.
According to EMS, the family noted that she
had been coughing for the past two days, and
had some vomiting. When she didn’t wake up
this morning, they found her in bed. She was
very sweaty, and felt hot. Every time they
tried to get her out of bed she got very
angry and was ‘talking out of her head.’ No
history is available from the patient, and
the family is on their way to the hospital.
According to EMS, she has some medical
problems, including Hypertension, but per
the family she is non-compliant.
No other information is available.
PE: Agitated, obese female very diaphoretic,
and intermittently trying to get off the
bed.
VS: HR=150, RR=28, Temp (oral) =103.6, Blood
Pressure=165/95, Oxygen Sat (RA) = 97%.
HEENT: Difficult exam as patient is
agitated, but pupils appear mid position and
reactive. Oropharynx is grossly
unremarkable. Neck supple.
HEART: Tachycardic, Systolic murmur at Left
Upper Sternal Boarder (2/6).
LUNGS: Clear bilaterally.
ABDOMEN: Obese, soft, no masses, appears
non-tender.
EXTREMITIES: +2 Edema
NEUROLOGIC: She withdraws to pain, responds
with inappropriate comments when stimulated
(will not answer questions), and appears
very agitated and confused. Eyes open to
pain. Babinski is down going, and reflexes
(patella) present. Motor appears grossly in
tact with good strength when resisting
interventions. Sensation also appears in
tact. No obvious nystagmus or trunk ataxia.
Accucheck is 110.
CBC: Hbg 11, WBC=12K
Lytes: K+=3.3, all others normal. Calcium,
Mg, normal, BUN mildly elevated (30), Cr
normal.
Urine: UCG neg. Trace ketones.
CT Head: Normal
CXR: RLL infiltrate.
EKG: Sinus Tachycardia at 150, No injury or
ischemia pattern.
Family arrives and notes she has a history
of hypertension, and is supposed to get some
treatment for something but she hasn’t gone
as she doesn’t have insurance and doesn’t
want to go. She is supposed to take a blood
pressure pill and another medication with a
long name that starts with a “P”.
After Labetalol, fluids, and Acetaminophen,
she remains agitated when stimulated. CT of
the head is negative. Vital signs are
improved with a HR after Acetaminophen of
120, Temp 99F, BP=158/100.
Questions:
1. What is the mortality rate of this
condition left untreated? What is the
mortality rate when treated?
2. What is the most common cause of this
condition? How is it diagnosed?
3. How is it treated? Does it make a
difference the order medications are given?
Click here for answers and to respond
