I think it is a little weird for a man in his 50’s to go to be on a Friday and not wake up til Monday morning. OK, he got up and staggered to the bathroom two times during that time but otherwise, must moaned whenever his wife tried to rouse him. She finally woke him up on Monday for work and he got upset, thinking it was Saturday morning!
Finally she brought him to the ER. He had virtually no recollection of the weekend except the vague idea that he had gone to the bathroom a couple of times. Otherwise, he was convinced it was Saturday.
His vitals were normal except for mild HTN. His exam was normal except mildly hesitating, tired speech and poor short term memory. Well, that, and a Babinski on the right. He could do serial 7’s though and had no weakness , sensory loss, or cerebellar findings. He was a heavy smoker and had HTN but nothing else of note.
CT and labs normal (except that his BUN was high indicating dehydration). Negative for drugs and ETOH. Diagnosis? You have only two tests to chose from – what are they? This sounds like a Dr Grumpy consult……
Brain MRI (or head CT if MRI not available). Stroke/bleed would be primary consideration.
If that’s negative, or if it shows temporal lobe T2 and diffusion signal, then LP.
Tha fact that’s he’s improving argues against HSV encephalitis and other CNS inffections, though.
Other possibilities would include toxic/metabolic, focal status epilepticus, and hypertensive encephalopathy.
I’ve had (many) similar cases, and posted this a while back
http://drgrumpyinthehouse.blogspot.com/2009/01/bright-families-and-sleepy-people.html
Dr Grumpy,,, even though the case of this patient and the many cases of your previous patients are almost exactly the same,, what would your next move be? do you need anymore tests that would confirm these 2 similarities? or are all the cases including this one the same diagnosis and cause? and what do both of you and ERP believe that this is?? or have you come to your conclusion that the patient may be suffering from a mild stroke that wasn’t bad enough for his wife to notice right away?? and that the CT scan did not show this either,so that you would need to do an MRI which would be my next test!( if I were a doc ,of course)and if MRI was Negative, then perhaps, it might have to do with his SPINE??????? I am anxious to see his diagnosis!
Remember Dr Grumpy, you only get ONE test to do. Which would it be (obviously this is a little game, he got shitloads of tests!). Oh, and as I said, the non – contrast CT was negative.
Either an MRI or a PET scan.
MRI. If it were negative LP.
MRI showed some mild periventricular white matter disease. No acute/subacute CVA.
LP also negative.
Oh well. I guess that’s why I don’t work at the WFMC.
WFMC? What the Fuck Medical Center?
BTW, he had an EEG that showed abnormalities c/w focal complex seizures….
carbon monoxide level……..??
What The Fuck Medical Center? I love it! There is one of those very near my home!
So likely focal status. I mentioned it in my original DDx, so at least I should get points for that!
True, true. You get 10/10 points Grumpy!
I agreed with the MRI, LP, and EEG, in that order. But is anyone else more concerned that the wife waited until Monday until she brought him in? Is that true love or what? I guess as long as he didn’t piss the bed, it was all good…LOL. But my wife assures me she would kick me out of bed Saturday am…
Happy Holidays all.
Actually, the first thing I would check would probably be blood glucose, followed by drugs of abuse. Then I’d get into labs and scans. Sounds like a call for Dr. Megaworkup
A