Case Challenge #1


A 27-year-old woman presents with sudden onset agitation and delirium. In the emergency department, she has incoherent speech and lashes out violently at staff. She is initially febrile (38.7ºC). She is admitted to the ICU for observation and after two days is intubated for deteriorating mental status. Prior to intubation, she is noted to have labile blood pressure alternating between hypertension and hypotension.


PMH/PSH: none known

Medications: none known

Allergies: none known

Social Hx: Lives alone, part-time student/barista, no tobacco or illicit drug use, never-smoker

Exposures: One pet cat, avid hiker (3-day backpacking trip in Oregon 1 week ago, swam in freshwater lakes)


Vital signs: Temp 101°F; HR 60-120 beats/min; RR 22 breaths/min; BP 80/40-170/100 mm Hg

General: intubated, sedated, does not follow commands

HEENT: normal

Lungs: clear

Heart: intermittently tachycardic (regular)

Abdomen: thin, nontender, no masses

Extremities: normal

Skin: no rashes

Genitourinary: normal

Neurologic: pupils reactive, normal reflexes, no voluntary movement


Admission Labs/Imaging:


CXR: normal

CT and MRI of the head (enhanced): normal

The answer will be posted on Friday. Leave a comment below to explain your answer!

Adapted from: A Barista With Autonomic Neuropathy and Delirium. Medscape. May 07, 2012