Neuro questions

[crimsonkid85]

I have a few questions for neuro:

63yo M POD1 s/p elective lumbar laminectomy has low grade fever 2/2 UTI. Has difficulty sleeping at night, and is treated with lorazepam. POD2, he is drowsy and confused. On exam: difficult to arouse, slurred speech; not oriented to place, or time. Cannot cooperate with motor exam. Otherwise PE is normal. Dx?

a. Cerebral infarction
b. Alzheimers dementia
c. metabolic encephalopathy
d. nonconvulsive status epilepticus
e. subdural hematoma

I literally have no idea what's going on here. I thought the AMS would be due to overloading an older person with benzos. Help???

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[ksmi117]

Benzos was my first thought too, but not a choice. My next best guess is metabolic encephalopathy. Could be urosepsis or electrolyte abnormalities 2/2 UTI.

 

[crimsonkid85]

thanks! that's what I guessed second time around too -- but I mean come ON now, if we're going down the 'let's make a story' path, we can say, pt got confused on benzos, probably FELL and got a subdural so now is confused....

speaking of which, I did actually have a patient on the neuro service who got benzos and then fell...and then got a subdural!

but anyway, thanks for your help! ughghgh sometimes i hate these make-up-a-story-about-your-patient-based-on-the-question-stem questions...

 

[ksmi117]

thanks! that's what I guessed second time around too -- but I mean come ON now, if we're going down the 'let's make a story' path, we can say, pt got confused on benzos, probably FELL and got a subdural so now is confused....

speaking of which, I did actually have a patient on the neuro service who got benzos and then fell...and then got a subdural!

but anyway, thanks for your help! ughghgh sometimes i hate these make-up-a-story-about-your-patient-based-on-the-question-stem questions...

I'd hope the shelf/Step 2 doesn't expect us to jump from benzos to fall to subdural. If the patient fell, I'd think that'd be important info that should be in the question stem, but I wouldn't put it past them. You're totally right that they expect us to deduce the story from vague details to figure out what the question is actually asking. It's so frustrating!

 

[mmmcdowe]

63yo M POD1 s/p elective lumbar laminectomy has low grade fever 2/2 UTI

UTIs are like catnip for old people

 

[Top Gun]

I would have to go with metabolic encephalopathy. The combination of urosepsis and benzos probably led to the altered mental status.

 

[jturkel]

neuro shelf isn't too bad. surprising amount of medicine on it