Altered mental status

43 year old white female was brought the emergency room with a one day history of altered mental status.  The evening prior to presentation her husband found her lethargic.  Her mental status deteriorated over the next 6 hours, and she was described as acting “drunk.”  She was stuporous, ataxic, and dysarthric, and vomited a few times.  There was no history of fever, chills, headache, abdominal pain, or dysuria.

She has had three similar episodes in the past six months during which she rapidly improved with fluid, electrolyte, and bicarbonate supplementation.

1. Small and large bowel infarction-In January of 2002, she had an extensive bowel infarction from her jejunum to the splenic flexure of her colon that was  attributed to use of oral contraceptives.  She was left with 80cm of small bowel that was secondarily reanastomosed to her descending colon.  She has suffered from short bowel syndrome since the resection and has 12-15 watery bowel movements daily
2. Deep venous thrombosis and pulmonary emboli-She developed a lower extremity deep venous thrombosis complicated by pulmonary emboli during the post-operative period after the bowel resection.  An inferior vena cava filter was placed; a hypercoagulability work-up was negative.
3. Internal hemorrhoids
4. Migraine headaches

1. Sodium citrate  8 tablespoons po QD
2. Potassium Chloride 40 mEq po BID
3. FeSO4  325mg po BID
4. CaCO3  500mg po BID
5. Multivitamin 1 tab po QD
6. Vitamins A, C, and E supplements
7. Dicyclomine 20mg po QID as needed for diarrhea
8. Loperamide 2-4mg po QID as needed for diarrhea
9. Ondansetron 4mg po TID as needed for nausea/vomiting
10. Zolpidem 10mg po qhs  as needed for sleep

She reports losing approximately 100 pounds since her small and large bowel   resection.  She denies recent changes in diet, changes in bowel habits,   hematochezia, melena, chest pain, arthralgias, rash, or sick contacts.

Vitals: Temp96.5  Pulse74  BP160/100 R24  SaO2 98%

General:  Thin, middle-aged white female who is somnolent, lying in bed.

HEENT:  Pupils were equal, round, reactive to light.  Sclera anicteric. Extraocular movements are intact.  Conjunctiva and mucous membranes are pink and moist.  Fundi without papilledema.  Oropharynx without exudates or lesions.

Neck:  Supple, no lymphadenopathy, jugular venous distension, thyromegaly, bruits, or meningismus.

Chest:  Clear to auscultation bilaterally.

Heart:  Regular rate and rhythm, normal S1, S2, no murmurs, rubs or gallops.

Abdomen:  Thin, multiple scars, soft, nontender, nondistended, normoactive bowel sounds.  Stool was yellow, guaiac negative.

Extremities:  Warm, 2+ distal pulses.  No lower extremity edema.

Skin:  No rashes.

Neurological:  She is somnolent and oriented x2.  She moved all four extremities spontaneously and purposefully.  Sensation was grossly intact to touch and pain.  Patellar and biceps reflexes were 2+.