A 75-year-old man is brought to the hospital for a 2-day history of intermittent confusion and agitation. He refused to allow his visiting nurse into his house for the first time. The patient was discharged from the hospital a week ago after a lumbar laminectomy due to degenerative disc disease. His other medical conditions include hypertension and chronic kidney disease. He takes lisinopril and acetaminophen/hydrocodone as needed for pain. Temperature is 38.5 C (101.3 F), blood pressure is 112/70 mm Hg, pulse is 102/min, and respirations are 16/min. Pulse oximetry is 97% on room air. On mental status examination, the patient gets distracted and is oriented to person but not time or place. Crackles are present at both lung bases. Heart sounds are normal. The abdomen is soft and nontender. The remainder of the physical examination shows no abnormalities. Laboratory studies obtained on arrival are as follows: What is the best next step in the management of this patient?

Question

A 75-year-old man is brought to the hospital for a 2-day history of intermittent confusion and agitation.  He refused to allow his visiting nurse into his house for the first time.  The patient was discharged from the hospital a week ago after a lumbar laminectomy due to degenerative disc disease.  His other medical conditions include hypertension and chronic kidney disease.  He takes lisinopril and acetaminophen/hydrocodone as needed for pain.  Temperature is 38.5 C (101.3 F), blood pressure is 112/70 mm Hg, pulse is 102/min, and respirations are 16/min.  Pulse oximetry is 97% on room air.  On mental status examination, the patient gets distracted and is oriented to person but not time or place.  Crackles are present at both lung bases.  Heart sounds are normal.  The abdomen is soft and nontender.  The remainder of the physical examination shows no abnormalities.  Laboratory studies obtained on arrival are as follows:  What is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1ba_f4e2_bc81_7f7109699a7a_MD0003_00 This patient has delirium as determined by the Confusion Assessment Method (CAM), which requires: an acute (eg, 2-day), fluctuating (eg, intermittent) course inattention (eg, easily distractible) and either disorganized thinking (eg, confusion) or altered consciousness The CAM is a validated screening tool that is both sensitive and specific for delirium. Risk factors for delirium in this patient include age, postoperative status, and opioid medications. Once recognized, delirium should be considered a medical emergency. Because delirium is often associated with an underlying medical condition, initial evaluation includes a history and physical examination, medication review, basic laboratory workup, and urinalysis to look for the most common causes. Abnormal findings help guide further evaluation and treatment. This patient's fever, crackles, and leukocytosis suggest underlying pneumonia, which warrants a chest x-ray. However, delirium is often multifactorial; if there is inadequate treatment response or initial workup is negative, extended investigation (eg, based on the patient's history) is warranted. (Choices B and D) CT scan of the head is indicated in patients with delirium when history (eg, headache, trauma, anticoagulation) or physical examination (eg, focal weakness, papilledema) suggests intracranial pathology; it is not initially necessary when focal neurologic findings are absent. Lumbar puncture is typically used to diagnose meningitis or encephalitis, which can cause fever and altered mental status and infrequently complicate spinal surgery. However, this patient does not have meningismus, and his fever and crackles are likely due to pneumonia. If initial workup is negative or treatment response is inadequate, neuroimaging and lumbar puncture should be considered. (Choice C) Electroencephalogram (EEG) can help identify occult seizures as the cause of altered mental status. Patients with a concerning history (eg, stroke, trauma, critical illness) or inadequate response to treatment of the underlying cause require EEG to rule out nonconvulsive seizures as the etiology of delirium. (Choice E) Renal ultrasound is useful to exclude complications of genitourinary infection (eg, perinephric abscess) and urinary tract obstruction accompanying acute kidney injury. This patient's findings do not suggest infection (eg, negative urinalysis) or retention (eg, no bladder distension on abdominal examination). His creatinine is likely elevated due to chronic kidney disease and dehydration. Educational objective: Delirium is an acute, fluctuating disturbance in attention, thinking, and consciousness. Abnormal findings on initial evaluation guide further investigation (eg, chest x-ray due to fever, crackles, and leukocytosis) and treatment. If initial evaluation is negative or there is inadequate response to treatment, extended investigation is warranted.

A 75-Year-Old Man Is Brought to the Hospital for a 2-Day