A 72-year-old man is hospitalized for a right femoral fracture following a motor vehicle collision. Six days after undergoing surgical repair, he is found to be lethargic. The patient has hypertension and osteoarthritis. His medications include hydrochlorothiazide, lisinopril, and naproxen, which were continued in the hospital. On examination, the patient is drowsy but awakens briefly when addressed by name. Temperature is 36.7 C (98 F), blood pressure is 144/76 mm Hg, pulse is 88/min, and respirations are 16/min. Pulse oximetry is 95% on room air. Multiple contusions are present in the anterior abdominal wall and thighs. Physical examination findings are shown in the video clip. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old man is hospitalized for a right femoral fracture following a motor vehicle collision.  Six days after undergoing surgical repair, he is found to be lethargic.  The patient has hypertension and osteoarthritis.  His medications include hydrochlorothiazide, lisinopril, and naproxen, which were continued in the hospital.  On examination, the patient is drowsy but awakens briefly when addressed by name.  Temperature is 36.7 C (98 F), blood pressure is 144/76 mm Hg, pulse is 88/min, and respirations are 16/min.  Pulse oximetry is 95% on room air.  Multiple contusions are present in the anterior abdominal wall and thighs.  Physical examination findings are shown in the video clip.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d47b_c1db_bc81_8b7be07527db_MD0003_00 The video clip demonstrates asterixis, a bilateral, nonrhythmic, alternate flexion and extension movement at the wrist (flapping) that occurs when the wrist is extended with the arms outstretched. Although classically associated with hepatic encephalopathy (HE), asterixis can also be seen with uremic encephalopathy (due to acute or chronic renal failure) and CO₂ retention. It likely develops due to interruption of the neural pathways that sustain muscle contraction. This patient has numerous factors that together can cause a severe degree of acute kidney injury. These include rhabdomyolysis from trauma (elevated creatine kinase), use of nonsteroidal anti-inflammatory drugs (eg, naproxen) and diuretics (eg, hydrochlorothiazide), loss of glomerular autoregulation with lisinopril, and anemia. Reduced renal clearance of uremic toxins leads to high levels of blood urea nitrogen (BUN) and symptoms of lethargy and somnolence. The diagnosis of uremia is based on clinical symptoms/signs and not on an absolute BUN level. Symptoms typically appear at a BUN level of >100 mg/dL but can develop at lower levels. Uremic encephalopathy is an indication for urgent hemodialysis. (Choice A) This patient has anemia but does not need a blood transfusion because his hemoglobin is >8 g/dL, he is asymptomatic, and he does not have ongoing bleeding. blood transfusion (Choice C) Intravenous lorazepam can be used to treat an ongoing seizure. (Choice D) Intravenous morphine is an opioid analgesic that may worsen this patient's drowsiness and lethargy. It may occasionally cause seizures or myoclonus. (Choice E) Lactulose is used for the management of HE in decompensated cirrhosis. Although asterixis may be seen in HE, this patient has normal bilirubin and albumin levels, suggesting normal liver synthetic function. His mildly increased aspartate aminotransferase level is likely from skeletal muscle injury rather than liver injury. (Choice F) This patient's high creatine kinase level is due to rhabdomyolysis associated with the motor vehicle collision and is not typically seen in acute coronary syndrome. Educational objective: Asterixis is a flapping movement of the hands that occurs when the wrist is extended with the arms outstretched. Common causes include hepatic encephalopathy, uremic encephalopathy, and hypercapnia. Treating the underlying cause will improve neurological status and resolve asterixis. References: Asterixis. (http://www.ncbi.nlm.nih.gov/pubmed/14597795)

A 72-Year-Old Man Is Hospitalized for a Right Femoral Fracture