GEM case 1

2 Feb

A 93-year-old man as brought to the ED by his wife and daughters for confusion.   He had a history of dementia with a gradual decline in his functioning over the past year. Twice in the past week, the staff at his housing found him in the hallways, seemingly agitated, and brought him back to the flat that he shared with his wife.

On the day of the ED visit, he was with his wife at the post office when he ran into the street, flagged down a garda and reported the he was being imprisoned. At this stage the family brought him to ED for evaluation. As per his wife he was eating well and had no vomiting or diarrhoea. He had not complained to his family about abdominal pain, nausea, urinary symptoms or chest pain. Though he had not complained of shortness of breath, his wife thought that he seemed to be wheezing that morning so had told him to use his inhalers.

His past medical history was notable for dementia, atrial fibrillation, ischaemic heart disease and COPD. He was an ex-smoker with a 40-pack-year history. He drank 3 pints per week. He was a retired army officer and lived with his wife in an inner city housing complex. Medications included digoxin, warfarin, Combivent, fluoxetine and lorazepem.

His vital signs were: T 37.0, HR 76, BP 163/88, RR 24 and sats 89% on room air. ON examination he was sleeping but awakened to voice and appeared comfortable. CVS exam showed an irregular pulse but no murmurs. He was tachypnoeic and had diffuse wheezing in the lungs fields bilaterally.   The abdomen was soft and non-tender. He had no lower extremity oedema or calf tenderness. Neurological exam showed normal CN exam, normal upper and lower limb power with no clonus or rigidity. He was orientated to person, reported the year as 1922 and stated that he was in prison. He had fluent but very tangential speech and fell asleep during the examination. When asked to recite the days of the week backward, he stopped at Wednesday and was not able to proceed.

A CT Head scan showed global atrophy with periventricular white matter hypo-densities consistent with chronic small vessel disease. A CXR demonstrated hyperinflation and flattening of the diaphragm but no acute infiltrate. The ECG showed AF with a ventricular rate of 70 and a RBBB, unchanged from previous ECGs. FBC, UEC and urinalysis were normal.   INR was therapeutic at 2.4.

 

Conclusion

The patient was thought to have delirium, likely secondary to an acute COPD exacerbation. He was given oral steroids, nebulizer treatments, placed on supplemental oxygen, and admitted to the hospital. The lorazepam was discontinued.   His mental status improved over several days and he was discharged home 4 days later at his baseline mental status.