Evaluation and Management of a 72-Year-Old Female with Altered Mental Status

QUESTION

D.B. is a 72 year old African American female who presented to the doctors office with complaints of headache, altered mental status that includes: confusion, lethargy, slurred speech, right sided weakness, and a facial droop that she says comes and goes. Symptoms started again today when patient woke up from a nap approximately one hour ago. Patient’s daughter is at bedside. Vital signs on arrival: HR 92 irregular, RR 12, BP 172/91, Temp 99.3, blood glucose 163. Based on the above information and the patients history, what would be your next course of action? What orders would you place, if any? What do you think is going on with the patient?

ANSWER

Evaluation and Management of a 72-Year-Old Female with Altered Mental Status

Introduction

D.B., a 72-year-old African American female, presented to the doctor’s office with a concerning array of symptoms, including headache, altered mental status (confusion, lethargy, slurred speech), right-sided weakness, and intermittent facial droop. Given these symptoms and her vital signs, it is imperative to consider several possibilities and determine the most appropriate course of action.

Assessment and Initial Observations

Vital Signs: The patient’s vital signs reveal an irregular heart rate (HR 92), elevated blood pressure (BP 172/91), and slightly elevated blood glucose (163). These findings raise concerns about a possible cardiovascular or neurological issue.

Neurological Symptoms: D.B. is experiencing alarming neurological symptoms, including confusion, lethargy, slurred speech, and right-sided weakness. The intermittent facial droop is a red flag that requires urgent attention.

Next Course of Action

Immediate Neurological Evaluation: Given the patient’s age, altered mental status, neurological deficits, and fluctuating symptoms, the first course of action should be an immediate neurological evaluation. A detailed neurological examination, including an assessment of cranial nerves, motor and sensory functions, coordination, and reflexes, is crucial.

Imaging Studies: Given the abrupt onset of symptoms and the possibility of vascular events, such as transient ischemic attack (TIA) or stroke, imaging studies are warranted. A non-contrast head CT scan should be ordered to rule out any acute intracranial pathology.

Cardiovascular Assessment: Given the irregular heart rate and elevated blood pressure, it is crucial to assess the patient’s cardiovascular status. An electrocardiogram (ECG) should be performed to assess for any cardiac arrhythmias. Additionally, a chest X-ray or other appropriate imaging may be considered.

Laboratory Tests: Routine blood tests, including a complete blood count (CBC) and comprehensive metabolic panel (CMP), should be ordered to evaluate for any underlying systemic issues that may be contributing to the symptoms.

Consultation with a Neurologist: Given the severity of neurological symptoms, consulting a neurologist is advisable to help determine the exact cause and guide appropriate management.

Working Diagnosis

Given the patient’s symptoms, the most concerning differential diagnosis is a possible cerebrovascular event, such as a TIA or stroke. The intermittent facial droop and right-sided weakness are particularly suggestive of a neurological issue. It is essential to rule out other potential causes, including cardiac arrhythmias and metabolic disturbances.

In summary, D.B.’s presentation of neurological symptoms and vital sign abnormalities necessitates urgent evaluation, with a focus on neuroimaging and cardiovascular assessment. Rapid intervention is critical in determining the underlying cause of her condition and initiating appropriate management to prevent further complications. The patient’s daughter should be informed of the situation and the course of action to ensure her involvement and support throughout the evaluation and treatment process.