Neurolist Case Study

Acute Deterioration of Mental Status

78 y/o AAF with history of HTN, diabetes, chronic renal failure on dialysis, and blindness due to diabetes presents with altered mental status. Patient's family states that patient has sustained a fall roughly 1-2 weeks ago. CT scan at the time revealed a mild subdural hematoma at the L occipital area and patient was admitted to the Neurosurgery service and discharged roughly 2 to 3 days prior to the current presentation. No surgery was performed for the hematoma. Since her discharge, family has noted decreased responsiveness, increased drowsiness, and mild worsening of her baseline mentation and decided to bring her back to the ER for further evaluation. Family states that similar episodes of altered mental status has happened in the past when patient's PICC line became infected. Family denied any further trauma or injury to the head, fever, vomiting, diarrhea, cough, dyspnea, or rhinorrhea. Patient was afribile at the ER. On physical exam, patient is sleeping but arousible with verbal stimulation. She was not oriented to person, time, or place. Per family, patient usually has difficulty with orientation to time and place due to her chronic blindness, but doesn't usually have difficulty recognizing family members. Patient is blind but demonstrates conjugate gaze with no gaze preference. Physical exam is otherwise normal and patient was noted to be able to move all extremities spontaneously. Urine analysis at ER revealed too numerous to count leukocytes and trace bacteria but negative nitrite. Except for the elevated BUN and Cr, CBC and CMP are within normal limits. CT scan at the ER showed no enlargement of the subdural hematoma or any new intracranial hemorrhage. Given the patient's prior history and findings on urinanalysis, it was felt that patient might have suffered from UTI, which resulted in mild deterioration of patient's mental status. Given her past history of similar episodes whenever her line became infected, blood cultures were also ordered to rule out line infection. IV antibiotics were started and patient was admitted to the Nephrology service.

One day after admission, patient was reevaluated and was found to be slightly more oriented and per family member, patient's mental status has also improved soon after IV antibiotics administration.

Three days after admission, Neurology service was consulted again because patient's mental status has suffered an acute deteriorate of her mental status. Per family member, patient was conversing appropriately with visiting family members the afternoon prior. Then, starting at around 7pm, patient suddenly stop carrying any conversation and become unresponsive to family members. On physical exam, patient was arousible upon verbal stimulation but was non-verbal. Patient also had decreased spontaneous movement of her R side body, which was a new finding compared to her admission exam. No gaze preference was noted. Repeat CT scan of the head was obtained. The scan showed improvement of her subdural hematoma but effacement of the gray-white matter junction, as well as decreased cortical sulci on the L parietal and occipital region. 

MRI study with DWI was ordered and scan showed DWI changes suggestive of L temproparietal-occipital lobe contusion with superimposed ischemia. Given the patient's extensive medical problem, it is felt that patient should remain in the Nephrology service with close Neurology follow-ups.