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Mr Potter is a 66 year old gentleman who lives alone independently.  He has presented to his GP, accompanied by his daughter, who is concerned he “just isn’t himself”.  She feels he is quieter than usual and has been sleeping for most of the past two days.

History

What questions would you like to ask Mr Potter to begin with?

Screen for confusion

Use the abbreviated mental test score (AMTS) or other tools (e.g. six item cognitive impairment test):

  1. Age?
  2. Time? (nearest hour)
  3. Address for recall at the end of the test (get patient to repeat back to ensure heard correctly  e.g. “42 West Street”).
  4. Year?
  5. Name of this place?
  6. Identification of two people (e.g. doctor / nurse)
  7. Date of birth
  8. Year of first world war?
  9. Name of the present monarch?
  10. Count backwards from 20 to 1

Address from question 3 recalled correctly?

 

Patient’s answer
Mr Potter remembers his name but struggles with his date of birth.

He believes the year is 1978 and he is at home.

His overall score is 5/10.

What further questions would you ask Mr Potter?

History of the presenting complaint

Do you feel confused? How long have you felt confused for?

Low mood? – symptoms may suggest depression

Appetite?

Weight change? –  malignancy / hypothyroidism

Have you fallen or injured your head recently? intracranial bleed

Any headache? – location / timing / worse when lying or standing? 

Any pain anywhere at the moment? – ask SOCRATES if present

Recent infective symptoms? – productive cough? / dysuria or urinary frequency? / fever? / abdominal pain?

 

Past medical history

What other medical conditions do you have? – diagnosis of cognitive impairment?

 

Medication history 

Medications? – recent changes? / anticoagulants or antiplatelets? / analgaesia (opiates)? 

 

Social history

Living situation – Who lives with this gentleman? / Is he coping?

Alcohol consumption? – How much and how often?

Recreational drug use?

 

Patient answer
Mr Potter denies any headache, but he appears rather blank as you continue to ask the further questions, failing to provide any meaningful answers.

How might you go about gaining some further details of the history?
A collateral history from the daughter may provide useful insights.
What questions would be useful to ask his daughter?
What is his usual state and how does this compare? – Has he been confused in the past?

What’s his normal level of function at home?Is he coping?

Any history of falls or trauma?

Previous similar episodes of confusion?

Past medical history?

Medications?recent changes?

Recreational drug or alcohol use?

 

Daughter’s answer
His daughter states that Mr Potter is normally “fully with it” and hasn’t been confused in the past, remaining fully independent at home. She isn’t aware of any recent trauma, but has noticed he has become increasingly unsteady on his feet over the last 6 months. She knows her father is on some blood pressure tablets and also on Warfarin for “a funny heart rhythm”.  She last took him to have a blood test to “check his Warfarin is working ok” about 4 weeks ago. She denies any knowledge of her father taking illicit drugs and he doesn’t drink alcohol.

Examination

On examination Mr Potter is confused but alert.

He is able to obey commands and his eyes are opening spontaneously.

What is his GCS?

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14

Examination findings

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Neurological examination of the upper and lower limbs:

  • Normal tone
  • Power 4/5 in right arm
  • Power normal in all other limbs
  • Brisk right biceps and triceps reflex
  • Reflexes normal in all other limbs
  • Normal co-ordination
  • Normal sensation
  • Mild right pronator drift

Cranial nerves – no deficits noted

On general examination you notice some scuffs to his left shoulder and left ear, with some mild bruising on his head just posterior to the ear.

What is the significance of the pronator drift?

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Indicates spasticity in that arm – suggestive of an upper motor neurone lesion 
What further investigations would you want to perform?
This gentleman needs referring urgently to hospital for a CT head.

Other investigations could include:

  • Bloods (FBC / U&E/ CRP / Bone profile / Magnesium / TFTs) –  useful to rule out any potential causes of confusion (e.g. electrolyte abnormality / infection / hypothyroidism)
  • Urine dipstick – ?UTI – common cause of confusion in the elderly
Given this gentleman is on Warfarin, what other blood test would be useful?
INR –  a raised INR would be a concern, as this could have caused or exacerbated intracerebral bleeding.

Investigations

Show scan result
A CT head is performed, the scan result is shown below. 

Diagnosis 

A little later that evening…

Whilst on the ward Mr Potter has another fall.

Afterwards his GCS begins to deteriorate.

His eyes are now only opening to pain, he is demonstrating a withdrawal response to pain and making incomprehensible sounds.

What could this deterioration in GCS suggest?

Potential extension of the subdural haematoma causing raised intracerebral pressure.

He may have developed  a separate intracerebral bleed (less likely).

He may be having a seizure although he isn’t demonstrating any typical seizure symptoms.

Who other than a neurosurgeon would be important to involve given his reduced GCS?

Anaesthetist

GCS 8 or below indicates significant risk of airway occlusion.

As a result the airway needs to be secured.

How has it changed from the previous?
  • Extension of the left subdural haematoma
  • Midline shift
  • Extra-axial soft tissue swelling on the left

 

Management

What would be the definitive management for this gentleman?

Burr hole evacuation of  the acute subdural haematoma

What medications might be useful for an acutely for the raised INR?
Vitamin K – not appropriate in this scenario (onset of action too slow)

  • Warfarin works by inhibiting the recycling of active Vitamin K, reducing its availability
  • This in turn decreases availability of Vitamin K dependent clotting factors (II, VII, IX, & X.)
  • Giving vitamin K therefore replenishes active vitamin K and allows production of the vitamin K dependent clotting factors.
  • Administered orally it reduces the INR within 24-48hrs.
  • Administered IV it reduces INR significantly within 12-14hrs.
  • In this situation there is active bleeding that needs to be managed using emergency surgery. As a result Vitamin K would not be a sufficient solution in the hyper-acute situation, given it will take at least 12 hours to have an effect.

 

Beriplex – needs discussion with haematology

  • Combination of blood clotting factors II, VII, IX and X, as well as protein C and S.
  • If the bleeding is significant and requires urgent surgery, vitamin K alone is too slow acting. As a result Beriplex is used to directly replace the clotting factors.
  • It is therefore very effective at reversing the effect of warfarin rapidly to allow emergency surgery to go ahead with a reduced risk of bleeding.
  • In this situation, Beriplex would seem more appropriate. However this decision would not be up to you and instead the neurosurgical team would discuss this with haematology to decide on the best course of action pre-operatively.

References

Click to show

1. CT Scan image – By Lucien Monfils (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.) or CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

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