Things not to miss - Chronic SDH

A 78 years old patient was brought to the hospital by his son. The son had noted his father was behaving oddly yesterday. He was increasingly forgetful. For half an hour he was muttering to himself. But by evening he had completely recovered. However, today morning he had urinated inside the house.

The patient denied any history of fever, headache, limb weakness or numbness.

The patient was a known hypertensive patient on losartan. But he was otherwise well.

On examination the patient was well alert and oriented. The house officer failed to elicit any positive physical signs.

As the father had fully recovered the son wanted to take him home against advice without further testing.

What would you do??
What are the possibilities?

 House officer was reluctant to send the patient back without being seen by a senior doctor.

He called the senior house officer, who came and ordered a non contrast CT brain.

CT scan showed a large SDH! It needed urgent neurosurgical intervention.


Lesson
  • Confusion, either persistent or intermittent may be the only sign of a serious illness in elderly people.

  • Common causes for confusion include
    • Infections - such as UTI, Pneumonia
    • CNS pathologies - Meningoencephalitis, stroke, postictal confusion, SDH.
    • Electrolyte disturbances - mainly hyponatremia

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