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Old 09-07-2012
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Post stroke or dementia

A 79-year-old woman was hospitalized 4 days ago after sustaining a right hip fracture in a fall. She underwent surgical repair with right hip replacement 3 days ago and did not fully awake from general anesthesia until 12 hours after extubation. As her alertness has increased, she has become increasingly agitated. The patient has a 4-year history of Alzheimer dementia. She has no other pertinent personal or family medical history. Current medications are donepezil, memantine, and low-molecular-weight heparin.


On physical examination today, temperature is 37.2C (99.0F), blood pressure is 100/68 mm Hg, pulse rate is 100/min and regular, and respiration rate is 18/min. The patient can move all four limbs with guarding of the right lower limb. She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus.


Which of the following is the most likely diagnosis?


(A) Acute stroke
(B) Acute worsening of Alzheimer dementia
(C) Meningitis
(D) Postoperative delirium
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Old 09-07-2012
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ans D ........
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Old 09-07-2012
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D, alternating between agitation and somnolence, post surgical patient after a big procedure with numerous co-morbidities
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Old 09-07-2012
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D...........altered sensorium.........delirium....acute presentation
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Old 09-07-2012
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Answer D waxing and waning level of consciousness - delirium from sedative drug withdrawal or surgery itself
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Old 09-07-2012
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Quote:
Originally Posted by Novobiocin View Post
A 79-year-old woman was hospitalized 4 days ago after sustaining a right hip fracture in a fall. She underwent surgical repair with right hip replacement 3 days ago and did not fully awake from general anesthesia until 12 hours after extubation. As her alertness has increased, she has become increasingly agitated. The patient has a 4-year history of Alzheimer dementia. She has no other pertinent personal or family medical history. Current medications are donepezil, memantine, and low-molecular-weight heparin.


On physical examination today, temperature is 37.2C (99.0F), blood pressure is 100/68 mm Hg, pulse rate is 100/min and regular, and respiration rate is 18/min. The patient can move all four limbs with guarding of the right lower limb. She is inattentive and disoriented to time and place and exhibits combativeness alternating with hypersomnolence. The remainder of the neurologic examination is unremarkable, without evidence of focal findings or meningismus.


Which of the following is the most likely diagnosis?


(A) Acute stroke
(B) Acute worsening of Alzheimer dementia
(C) Meningitis
(D) Postoperative delirium


D.) post-operative delirium
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The most likely diagnosis is postoperative delirium. Patients with delirium have acute, fluctuating mental status changes, with difficulty in focusing or maintaining attention and disorganized thinking.


The possibility of acute stroke must be considered in a patient with a change in mental status. However, this patient has no clinical evidence of such an event, which makes this diagnosis extremely unlikely.


Surgery does not exacerbate Alzheimer dementia (or dementia of any other cause) but rather produces a superimposed delirium. Finally, dementia does not acutely worsen over several hours; the decline is steadily progressive.

Although not impossible, meningitis is highly unlikely in this setting, especially given the absence of any supporting physical examination findings, including meningeal irritation.
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