CPC

PENN STATE EMERGENCY RESIDENCY CONFERENCE

APRIL 2023
 CPC

A rare presentation of a common disease or a

common presentation of a rare disease
 Chief Complaint

 RN triage note:
“Pt hit head on windowsill x 6 weeks ago. had MRI 2 weeks ago.
showed small amount of blood at base of skull. daughter brings patient
in w c/o rapid decline, in confusion, mental acuity, balance c/o. pt
repetive in speech, slightly irratic.“
 ED HPI

 “61-year-old female with a past medical history of tobacco use, untreated HCV who
presents with altered mental status. The patient was seen at HMC 6 weeks ago,
following a fall. She states that she hit the back of her head on a wooden windowsill.
Work-up at that time revealed a small left frontal punctate bleed, but no vital sign
abnormalities or other concerning midline shift/mass-effect during that time. She
was discharged home to follow-up. Reportedly was at her mental status baseline for
a period following discharge. Since then, both of her daughters state that the patient
has become increasingly erratic. She has had outbursts of anger. She is seemed
confused and altered. They state that she is drinking more alcohol often, and not
taking care of herself. She lives alone, and she is frequently have an ataxic gait and
multiple falls per the daughters. This is never happened before. No family history of
sudden onset dementia. No recent new foods. Hepatitis C was reportedly treated
and controlled per patient and daughters. The patient has been confabulating as
well. The daughters and the patient have not noticed any chest pain, difficulty
breathing, nausea, vomiting, fever, lethargy, visual changes, focal deficits.”
 Additional history
 “Since (prior head injury) then she reportedly had returned near her cognitive baseline (was
watching grandchildren and working; however, had continued poor balance (unstable gait,
progressed to needing a rolling walker for ambulation). Multiple recent falls. Bilateral hand
shaking with using utensils and glasses - not at rest. Daughter thought patient's speech was
slurred, "like she was drunk." Recent erratic behavior - attempted to contact her ex-
husband (had not spoken to in ~24 years) and placed her SSN and bank account
information on Facebook yesterday (daughter took the post down). Increased paranoia -
per daughter thinks everyone at work was "against her." Difficulty making full sentences
and words. Labile mood and affect (goes quickly from crying to anger). Disrupted sleep
with hypersomnolence - ~12 hours at a time. She reportedly has not left her home in ~5
days, usually walks across the street to visit her daughter daily. Can no longer write or
manage her finances. Poor short-term and long-term memory loss. Afraid to use utensils as
she "stabbed" her self by mistake with a pen. Easily startled with a wide eyed presentation
upon awakening per daughter. Waves to family like she is a "child" per daughter. Poor PO
intakes - ~20 lbs weight loss in the past two weeks. Headache and tooth infection per
daughter. Denies any recent illness. Denies any new medications. Denies history of
psychiatric disorder.”
 Medical History

 Medical Hx: Hep C s/p treatment. Recent visit for head injury 6 weeks ago with
possible small focal cortical contusion with small amount of blood products on
MRI.
 Surgical Hx: Liver biopsy
 Social Hx: Drinks ETOH per family regularly, ½ PPD smoker x many years, occ
marijuana, lives alone across the street from adult child
 Home Meds: None
 Allergies: Sulfa
 Fam Hx: None known
 Physical Exam
T 36.2 HR 86 BP 146/92 RR 18 Sat 97% RA
 General: Alert, no acute distress.
 Skin: Warm, dry.
 Head: Normocephalic, atraumatic.
 Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva.
 Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate.
 Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion, No edema.
 Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal, Symmetrical
chest wall expansion.
 Gastrointestinal: Soft, Nontender, Non distended.
 Back: Nontender, Normal range of motion.
 Musculoskeletal: Normal ROM, normal strength, no tenderness, no swelling, no deformity.
 Neurological: AOx3. Intermittently angry and agitated. No obvious focal deficits. Ataxic gait. Poor thought content,
confabulations. Unable to follow complex commands.
 Lymphatics: No lymphadenopathy.
 Psychiatric: Agitated.
 Labs

 Na 143 K 4.6 Cl 102 CO2 25 BUN 26 Cr 0.97 Glu 123 Ca 10.8

 CBC WBC 7.58 Hgb 15.1 Hct 44.7 Plts 279 MCV 88.9
 TSH 0.92 B12 512 Folate 17.3 ETOH Neg
 UA: WBC 0-4 RBC 0-4 Neg Nitrites, + LE, few bacteria, few squam epithelial
cells
 Imaging

 CT head w/o contrast: No acute abnormality

 MRI/MRA brain: IMPRESSION: Scan is severely limited by motion artifacts. No

large territory ischemia, abnormal enhancement or acute intracranial hemorrhage.
 Your Challenge

 The patient is admitted and THIS diagnosis is ultimately confirmed