Case Study
April 6, 2010
Primary Diagnosis
Lung CA with acute mental status change secondary to underlying pneumonic process.
Abstract
On April 3, 2010 a 61-year-old white female, suffering from a pancoast tumor, presented to the emergency room with altered levels of consciousness and confusion. The patient had gone through her fifth cycle of chemotherapy when she became very confused today. She was then brought to the emergency room where she was evaluated and had testing done. A CT scan of the patients head showed no signs of acute abnormalities. The chest x –ray re-demonstrated the pan coast tumor with possible underlying infection. Sinuitis also was noted on the CAT scan. The patient was admitted to the floor because of her shortness of breath and level of confusion. Antibiotics were administrated for the pneumonic process and Neupogen was given. The patient was put on oxygen therapy and aerosol treatments and later was transferred to the ICU because of respiratory failure. The patient was placed on a mechanical ventilator when sent to ICU with the new status of DNRCC-A and was extubated on 3/6/10 and died.
Past Medical History
The patient has a history of depression and acute mental status change. The patient has a surgical history of an A-port insertion.
History of Present Illness
The patient came into the emergency room complaining of confusion and weakness after her fifth cycle of chemotherapy was done earlier that day.
Physical Exam on Admission Vital Signs | Actual Values | Reference Values | Temperature | 98.7F | 97.0- 99.5F | Respiratory Rate | 20 bpm | 12- 20 bpm | Pulse | 121 bpm | 60- 100 bpm | Blood Pressure | 151/79 mm Hg | 60-90/90-140 mm Hg | Weight | 85 lbs | 115 lbs |

HEENT: No abnormalities
Neck: No abnormalities; no masses present
Pulmonary: Shallow respirations with decreased breath sounds bilaterally with