Easy Kquestions - unum35

[ArchivalUser]

An 81-year-old woman is admitted to the medical floor for depression and questionable dementia. She
has a past medical history of insulin-dependent diabetes mellitus, hypertension, and an anterior wall
myocardial infarction 10 years ago. She takes nifedipine, atenolol, insulin, aspirin, furosemide,
simvastatin, multivitamins, docusate sodium and was recently started on methylphenidate for
depression by her primary care physician. She lives at home and her family reports that she has
become increasingly withdrawn and confused over the past few months.She is an obese woman in no
distress with normal vital signs. Her neck is supple with a normal thyroid, clear lungs, and 1+ non-pitting
lower extremity edema. She is alert to person, month, but not to date or location. She has poor
concentration. In addition to evaluation of her medication list for potential causes of confusion, the most
important test to order in the evaluation of this patient's confusion is


A. calcium level

B. diffusion weighted MRI of brain

C. head CT scan with contrast

D. rapid plasma reagin test

E. thyroid stimulating hormone

[ArchivalUser]

E?

[ArchivalUser]

E

[ArchivalUser]

E , it makes sense to check Thyroid function

[ArchivalUser]

serum calcium will also have been ok to order but considering there are no other signs of hypocal, i dont think u need to check ca

[ArchivalUser]

Explanation:

The correct answer is E. Hypothyroidism is an uncommon cause of confusion. However, in the
elderly, especially women, hypothyroidism or subclinical hypothyroidism is extremely common; up to
20% of all medical inpatients in some series. Given this, the evaluation of new confusion or suspected
dementia should always include a screening TSH level when the patient is of this age
demographically.

Calcium level (choice A) is included as well in the initial laboratory evaluation, but interpretation of
this test is difficult. The primary reason for this is that asymptomatic hypercalcemia is very common in
the elderly, with as much as a 50% prevalence rate. Given this, even the finding of elevated total
serum calcium is without obvious significance and hypothyroidism is still a much more common
cause of altered mental status despite its lower prevalence.

Diffusion weighted MRI of brain (choice B) is an MRI that uses diffusion weighting which allows
visualization of areas of acute infarction. This is only used in special circumstances when the question
of an evolving infarct is suspected.

Head CT scan with contrast (choice C) is not indicated unless there is clinical suspicion for old
infarcts or a bleed.

Rapid plasma reagin test (choice D) is the screening test for syphilis. Although this test is routinely
sent with the panel of tests for the evaluation of dementia, tertiary syphilis is exceedingly rare and not
a very common cause of dementia in any age demographic in the United States.