This week’s free board review question…
An 88-year-old man presents with a history of increasing confusion and lethargy progressing to obtundation over the past 12 hours.
Vital signs are: Temperature 101.60F, blood pressure 88/60 mm Hg, pulse 120 beats/minute and regular, and respiratory rate 20 breaths/minute.
General physical examination is normal with the exception of decreased mentation. There are no focal neurologic signs.
Laboratory studies include:
- Hct: 36%
- WBC: 13,400/mm3
- WBC differential: 82% neutrophils, 8% band neutrophils, 10% lymphocytes
- Electrolytes: Normal
- Blood urea nitrogen: 35 mg/dL
- Creatinine: 2.5 mg/dL.
- Urinalysis is positive for leukocyte esterase and is packed with bacteria and white blood cells.
If the patient does not respond to initial treatment with boluses of intravenous fluids, then what is the most appropriate next step?
Elevate the lower end of the bed
Replace normal saline with lactated Ringer solution
Perform central venous monitoring to maintain left heart–filling pressures between 8 and 12 mm Hg
This question is a just sample from this week’s Free online medical education Quick Quiz.
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