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2. A 72-year-old woman with metastatic rectal cancer is admitted to the hospital because of weakness and altered mental status. She has bilateral ureteral stents due to prior obstruction from the cancer. She has been using a fentanyl patch for several weeks. Physical examination on admission is notable for lethargy and 3-mm reactive pupils but no focal neurologic signs. She is afebrile and has a blood pressure of 120/82 mm Hg. Laboratory studies show serum urea nitrogen (BUN) concentration of 60 mg/dL and a serum creatinine concentration of 6.2 mg/dL. Serum bilirubin concentration is normal. One week ago serum BUN concentration was 30 mg/dL and serum creatinine concentration was 3.0 mg/dL. Which of the following is the most likely explanation for her altered mental status? A) Fentanyl intoxication B) Hepatic encephalopathy C) Hypercalcemia D) Uremia E) Urosepsis

i think [D]

ddd

why not urosepsis, becoz she is afebrile?

its more likely to be D

the pt doesnt seem to be in sepsis,as there is no fever or any sign or symptoms of infection {esr.leucocytes}

THE ANSWER IS D...THE patient is not febrile or unstable in terms of her vitals...BP is normal...so sepsis doesnt really come into the picture...also the patient has a BUN/Cr level which has nearly doubled within a short period of time...in lieu of his renal insufficiency the build up of waste products has lead this patient to have altered status..this patient is going towards the need for dialysis, if u remember uremia encephalopathy is one of the indication for dialysis. Cancer patients who are also on long term drug therapy tend to have in turnover of cells and breakdown increasing the waste load on the liver and kidneys...so D is more probable.

Uremia