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Octogenarian With Intermittent Confusion

Octogenarian With Intermittent Confusion

Intermittent, worsening confusion recently developed in
an 82-year-old man. His daughter brings him to the office
for evaluation.

History. The patient lives alone and is self-sufficient;
he cooks, gardens, and manages his own finances. For
the past 2 days, however, he has become
increasingly forgetful. For example,
he misplaced his car keys, got
lost when he returned home from a
walk, and did not recognize his sonin-
law. His gait has also been unsteady
recently. Yet at times he seems
to be his former self.

The patient denies fever, cough,
chest pain, dyspnea, palpitations,
GI symptoms, headache, vision problems,
weakness, paresthesias,
seizures, syncope, and bladder dysfunction.
His weight has been steady.
About 3 days earlier, he fell when he
got up in the middle of the night, but
he sustained no external injuries.

The patient has hypertension and moderately severe
degenerative joint disease of the hips, knees, and shoulders.
His medications include lisinopril, 10 mg/d; ibuprofen,
800 mg tid; aspirin, 81 mg/d; and a multivitamin supplement
once daily.

Examination.The patient is well nourished but unkempt
and unshaven. Pulse rate is 66 beats per minute
and regular; respiration rate, 22 breaths per minute; blood
pressure, 148/72 mm Hg sitting and 142/70 mm Hg
standing. He is afebrile and well hydrated. No pallor,
cyanosis, clubbing, adenopathy, or rashes. Thyroid is not
palpable. Varicose veins noted in lower limbs; no sensory
deficit. Crepitus is audible when knee joints move; no
swelling observed.

Skull and spine are normal; carotid arteries are equal
and palpable. The patient is disoriented to time and space
and is unable to recall his address or telephone number.
However, he recognizes his daughter and can recite the
names of his grandchildren. Cranial nerve function is intact;
funduscopy reveals arteriosclerotic changes. His left
pupil is dilated and poorly reacting. No motor or sensory
deficit is noted. Deep tendon reflexes are equal bilaterally,
and plantar reflexes are flexor. There
are no meningeal or cerebellar signs.
The remainder of the systemic examination
is normal.

Laboratory studies.White
blood cell count is 7200/μL, with a
normal differential count; hemoglobin
level, 13.8 g/dL; platelet count,
192,000/μL; erythrocyte sedimentation
rate, 16 mm/h. Urinalysis results
are normal. Serum sodium level is
138 mEq/L; potassium, 4 mEq/L;
chloride, 100 mEq/L. Blood bicarbonate
level is 24 mEq/L; blood urea
nitrogen, 18 mg/dL; creatinine,
1 mg/dL; glucose, 108 mg/dL.

An ECG shows sinus rhythm
with nonspecific ST-segment and T-wave changes. Radiographs
of the chest and skull are normal.

What abnormality does the noncontrast head CT scan
show, and to which of the following disorders does the
clinical picture point?
A.Cerebral tumor

B.Subdural hematoma

C.Normal-pressure hydrocephalus

D.Alzheimer disease
E. Multi-infarct dementia

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