A 76-year-old woman is brought to the hospital due to confusion for the past hour. The patient's husband says she started having an occipital headache 2 hours ago and took acetaminophen and went to bed. An hour later, he had difficulty waking her and found her confused. Medical history is significant for hypertension and seizure disorder. The patient takes phenytoin, amlodipine, and lisinopril. She lives with her husband and is independent in her daily activities. Temperature is 37.9 C (100.2 F), blood pressure is 170/100 mm Hg, and pulse is 70/min and regular. The patient is somnolent but wakes up with painful stimuli and withdraws all 4 extremities to pain. She is unable to follow simple commands and mumbles a few unintelligible words. Deep tendon reflexes are symmetric, and Babinski sign is absent bilaterally. Fingerstick blood glucose is 110 mg/dL. Which of the following is the best next step in management of this patient?

Question

A 76-year-old woman is brought to the hospital due to confusion for the past hour.  The patient's husband says she started having an occipital headache 2 hours ago and took acetaminophen and went to bed.  An hour later, he had difficulty waking her and found her confused.  Medical history is significant for hypertension and seizure disorder.  The patient takes phenytoin, amlodipine, and lisinopril.  She lives with her husband and is independent in her daily activities.  Temperature is 37.9 C (100.2 F), blood pressure is 170/100 mm Hg, and pulse is 70/min and regular.  The patient is somnolent but wakes up with painful stimuli and withdraws all 4 extremities to pain.  She is unable to follow simple commands and mumbles a few unintelligible words.  Deep tendon reflexes are symmetric, and Babinski sign is absent bilaterally.  Fingerstick blood glucose is 110 mg/dL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d53c_ef4e_bc81_517ae5f9d5f7_MD0003_00 This patient's acute onset of altered mental status (eg, confusion, somnolence) and headache in the setting of hypertension are concerning for stroke. Because the efficacy of stroke treatment (eg, systemic thrombolytics) is time dependent (ie, "time is brain"), a noncontrast CT scan of the head should be performed emergently whenever stroke is suspected. Noncontrast CT scan can rapidly differentiate between hemorrhagic and ischemic stroke: Hemorrhagic stroke: Hemorrhage is immediately evident as a hyperdense (ie, white) area within the brain parenchyma. Ischemic stroke: Hyperdense hemorrhage is absent. Subtle signs of ischemia (eg, loss of grey-white matter differentiation, hypoattenuation of deep nuclei) may be present, but CT is often normal in early (eg, <6 hr) ischemic stroke. CT scan findings help direct management. For patients with CT scan evidence of hemorrhagic stroke, thrombolytics are contraindicated; instead, blood pressure is controlled, anticoagulation is reversed (when applicable), and neurosurgery is consulted emergently. In contrast, patients without hemorrhage on CT scan are considered to have ischemic stroke and may be candidates for thrombolytic therapy and/or mechanical thrombectomy. thrombolytic therapy (Choice A) In patients with suspected stroke, a noncontrast CT scan is always completed prior to administration of intravenous contrast. Intravenous contrast is hyperdense and can make acute blood (also hyperdense) difficult to differentiate from surrounding structures that have received contrast. (Choice C) Nonconvulsive status epilepticus can cause impaired consciousness without convulsive movements in the setting of seizure disorder. However, it is extremely uncommon and typically considered only after other urgent conditions (eg, stroke) have been ruled out. This patient's occipital headache and hypertension raise concern for stroke; rapid noncontrast CT scan of the head should be performed prior to electroencephalography. (Choice D) Lumbar puncture (LP) can help evaluate for acute bacterial meningitis. Although meningitis can cause altered mental status and fever, fever is typically >38 C and symptom onset is more gradual. In addition, when altered mental status is present, CT scan of the head is obtained prior to LP to exclude a mass lesion or increased intracranial pressure, which may lead to brain herniation if LP is performed. (Choice E) Chronic phenytoin toxicity can cause altered mental status but is typically gradual in onset and preceded by an ataxic gait and horizontal nystagmus. In addition, hyperreflexia (vs normal reflexes) is often present. (Choice F) A urinary tract infection complicated by sepsis can cause fever and somnolence. However, symptoms typically come on gradually, not within 2 hours. In addition, a preceding occipital headache is unexpected. Educational objective: In patients with suspected stroke, noncontrast CT scan of the head should be performed emergently to differentiate hemorrhagic versus ischemic stroke and guide further management. References: Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/31662037) Imaging of acute stroke. (http://www.ncbi.nlm.nih.gov/pubmed/20842186)

A 76-Year-Old Woman Is Brought to the Hospital Due to Confusion