Acute Confusion, Excessive Thirst

October 1, 2018

ECG Challenge: A 72-year-old woman is seen with generalized weakness x1week, acute altered mental status, and polydipsia. What's your ECG read?

Acute Confusion and Excessive Thirst in a 72-year-old Woman: What's Your ECG Read?

A 72-year-old woman is seen in the emergency department for asthenia that has been present for approximately 1 week and confusion that her family says began yesterday and seems to wax and wane. She denies other symptoms but asks repeatedly for cups of water.

Vital signs are normal other than pulse of 48 beats/min and slightly elevated blood pressure. Findings of physical examination are mostly normal other than dry mucous membranes and mild bradycardia.

The initial differential diagnosis is broad and includes a cardiovascular accident, urinary tract or other infection, electrolyte abnormality, and dehydration.

Initial diagnostic testing. ECG tracing is shown above. What clues does the tracing provide? What are the next steps?

ECG read, next steps. The ECG shows bradycardia with first-degree heart block and a prominent U wave. Labs should be ordered immdiately.

Rehydrate, treat, admit. Lab results showed a normal postassium level but the patient's calcium was >15 mg/dL. A diagnosis of hypercalcemia was made.

Hypercalcemia at-a-glance.

ECG read in hyperglycemia. FIndings may inlcude elevation of ST segment and/or J point and/or U wave; also lengthening of the PR and/or QRS interval.

Treatment for hypercalcemia. Fluid repletion is first and foremost followed by treatment with antiresorptive agents such as calcitonin and zoledronic acid. Calcium levels >13 mg/dL require hospitalization and >14 mg/dL admission to telemtry unit plus renal consult. The case patient's calcium was 15.5 mg/dL and the cause was determined to be multiple myeloma.

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Acute Confusion, Excessive Thirst

Brady Pregerson, MD