A 79-year-old woman is brought to the emergency department by her son due to worsening lethargy, confusion, and irritability over the past 2 weeks. The patient has lived by herself since the death of her husband a year ago, but her son frequently visits and helps her with grocery shopping and laundry. Her son says that the patient has had frequent falls at home and that he has asked her to come live with him but she has refused. He also states that she has not been as socially active as she was before her husband's death and that she has been drinking alcohol more frequently. Medical history includes hypertension and hyperlipidemia, but the patient is not adherent with medications or follow-up visits. She is a lifetime nonsmoker.
Blood pressure is 155/80 mm Hg and pulse is 78/min. The patient is somnolent but wakes easily to voice. She is oriented to place and person but not to time. Cardiopulmonary examination reveals no abnormalities. The abdomen is soft and nontender with normal bowel sounds. Cranial nerve examination is normal. She has mild weakness of the left leg with exaggerated knee reflex, but all other deep tendon reflexes are normal. Vibration sensation is decreased in both feet. Romberg test with eyes closed reveals mild unsteadiness.
Which of the following is the best next step in management of this patient?

Question

A 79-year-old woman is brought to the emergency department by her son due to worsening lethargy, confusion, and irritability over the past 2 weeks.  The patient has lived by herself since the death of her husband a year ago, but her son frequently visits and helps her with grocery shopping and laundry.  Her son says that the patient has had frequent falls at home and that he has asked her to come live with him but she has refused.  He also states that she has not been as socially active as she was before her husband's death and that she has been drinking alcohol more frequently.  Medical history includes hypertension and hyperlipidemia, but the patient is not adherent with medications or follow-up visits.  She is a lifetime nonsmoker.
Blood pressure is 155/80 mm Hg and pulse is 78/min.  The patient is somnolent but wakes easily to voice.  She is oriented to place and person but not to time.  Cardiopulmonary examination reveals no abnormalities.  The abdomen is soft and nontender with normal bowel sounds.  Cranial nerve examination is normal.  She has mild weakness of the left leg with exaggerated knee reflex, but all other deep tendon reflexes are normal.  Vibration sensation is decreased in both feet.  Romberg test with eyes closed reveals mild unsteadiness.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient with a history of alcohol consumption and falls now has lethargy, confusion, and focal weakness, raising suspicion for a chronic subdural hematoma (SDH). Acute SDH typically presents with coma (50% of cases), sometimes after a transient "lucid interval" followed by rapid neurologic decline. Chronic SDH, which is more common in the elderly and in patients who abuse alcohol, frequently presents with insidious onset of more global deficits. These include headaches, lightheadedness, cognitive impairment, personality changes, and somnolence. Focal deficits (eg, left leg weakness) are rare but can occur ipsilateral or contralateral to the bleed. Symptoms may present weeks after initial trauma and may fluctuate. Diagnosis is suggested by the presence of a crescent-shaped extra-axial lesion on head CT scan. head CT scan (Choice A) Depression in a geriatric patient may present as dementia syndrome of depression (previously known as pseudodementia) with memory and language deficits; however, it does not typically cause somnolence, proprioceptive changes, or focal deficits. (Choice B) Alcohol abuse may cause recurrent falls but would not cause focal leg weakness, and it typically does not lead to somnolence unless the patient is actively and markedly intoxicated. Although the patient needs counseling about alcohol abuse, head CT scan is more important initially to rule out intracranial hemorrhage. (Choice D) Neurosyphilis can cause sensory ataxia, behavioral changes, and confusion. However, it is typically associated with pupillary irregularities (eg, Argyll Robertson pupil) and lancinating pain, and it is uncommon in the era of antibiotics. (Choice E) Vitamin B₁₂ deficiency can cause neuropsychiatric changes and numbness, but it typically occurs with glossitis and anemia and is unlikely to cause somnolence or focal neurologic changes. Ruling out SDH is the first priority in this patient. ₁₂ Educational objective: Subdural hematoma should be suspected in an elderly patient presenting with new confusion, personality changes, headache, or lethargy in the setting of possible head trauma. Diagnosis is suggested by the presence of a crescent-shaped extra-axial lesion on head CT scan. __________ References: Cerebral atrophy is associated with development of chronic subdural hematoma. (http://www.ncbi.nlm.nih.gov/pubmed/22759238)

A 79-Year-Old Woman Is Brought to the Emergency Department by Her