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8/14/01
Texas Tech University Health Sciences Center
School of Medicine
AAMC/Hartford Geriatrics Curriculum
MS IV: NEUROLOGY CLERKSHIP
Case # 12
A 75-year-old woman is brought to the emergency room by police when she was found wandering the
streets in her nightgown. The police report that she was confused and could not tell them where she
lived. As she came into the emergency room, she became abusive and agitated. She looked frightened
and pale. She is unable to give additional history as to where she lives, but does give her name as Mrs.
Homer. She is unable to give her date of birth, but thinks she is “70 something”.
MEDICATIONS: “Something for blood pressure.”
PAST MEDICAL HISTORY: Unknown.
FAMILY HISTORY: Unknown.
PERSONAL/SOCIAL HISTORY: Unknown.
REVIEW OF SYSTEMS: Review of systems is unable to be obtained.
PHYSICAL EXAMINATION: This is an elderly woman who appears preoccupied and confused, and
generally does not answer any questions at all. Occasionally she is able to focus on a question and then
starts rambling in a disorganized way. Her speech sometimes is almost incoherent. At other times, she
is somewhat drowsy and nearly falls asleep during the interview. When awake, she seems to be talking
about things that are in the room with her and is unable to describe where she is, who she is or where
she lives.
Pulse is 100, temperature 99.1° F., blood pressure 160/90. She is somewhat diaphoretic. Since the
patient is only intermittently cooperative, a full mental status examination is unable to be done. She
appears generally clean, well nourished, and there is no sign of injury or falling. There are no carotid
bruits. No heart murmur. Lungs are clear. Abdomen is soft and non-tender, but she resists the exam.
Rectal exam not performed because of patient’s agitation. On neurological examination, there is diffuse
hyperreflexia and a mild tremor in her hands. During the Babinski examination, she withdraws bilaterally
and screams at the stimulus. You decide to observe her in the emergency room for an hour and she is
basically unchanged.
INITIAL DISCUSSION QUESTIONS:
1. What are your initial impressions? How would you proceed in this case?
2. What laboratory studies or imaging studies would you do initially?
3. Is there any immediate treatment that you would start without knowing any further information?
4. For next week choose a question related to delirium and get at least 3 references. Be prepared
to give a brief presentation.
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