History and Present Illness

A 72-year-old man with a history of bradycardia and transient ischemic attack (TIA) is transported from a skilled nursing facility for evaluation of altered mental status. In the emergency department (ED) he is alert but when asked cannot give any medical history. His medical records show that he was prescribed sulfamethoxazole and trimethoprim for treatment of a urinary tract infection.

Vital Signs and Physical Examination

The patient’s vital signs are normal except for a pulse rate of 40 beats per minute and hypothermia (85 ⁰F). His mental status is altered and he is nonverbal but nonfocal neurologically. The monitor shows that he has atrial fibrillation with rates between 32 and 60 beats per minute. His blood pressure is 122/66 mm Hg.

Laboratory results are normal except for low sodium level (129 mEg/L) and low platelet count of 22 x 103/µL. An electrocardiogram (ECG) reveals sinus bradycardia (40 beats/min) and Osborn waves (J waves). A computed tomography (CT) of the head is ordered (Figure).

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Case outlines the workup and treatment for a nursing home patient with altered mental status.

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