What diagnostics would you perform in the ER for a patient with a history of fall, somnolence, shortness of breath, and painful urination, who is taking escitalopram (citalopram)?

Diagnostic Approach for a Patient with Fall, Somnolence, Shortness of Breath, and Painful Urination Taking Escitalopram

For a patient presenting with a history of fall, somnolence, shortness of breath, and painful urination who is taking escitalopram, a non-contrast head CT should be performed first, followed by urinalysis, complete blood count, basic metabolic panel, and chest imaging to evaluate for both neurological and urinary tract causes of symptoms.

Initial Neurological Evaluation

Head Imaging

• Non-contrast head CT is the first-line imaging test for patients with altered mental status (somnolence) and history of falls 1

  • Evaluates for intracranial hemorrhage, mass effect, hydrocephalus, or other acute pathology
  • Particularly important in elderly patients where falls may cause subdural hematomas even without obvious trauma

• Consider brain MRI if CT is negative but neurological symptoms persist

  • Higher sensitivity for detecting ischemia, encephalitis, or subtle cases of subarachnoid hemorrhage 1
  • May be necessary if initial CT is unrevealing but clinical suspicion for intracranial pathology remains high

Urinary System Evaluation

Urinalysis and Culture

• Complete urinalysis with microscopy to evaluate for urinary tract infection
  • Essential given the complaint of painful urination
  • Urinary retention is a reported adverse effect of escitalopram 2
  • Evaluate for pyuria, bacteriuria, hematuria, and nitrites

Renal Function Tests

• Basic metabolic panel to assess:
  • Electrolytes (particularly sodium) - escitalopram can cause hyponatremia 3
  • BUN/creatinine to evaluate kidney function
  • Glucose levels to rule out hyperglycemia or hypoglycemia as causes of altered mental status

Respiratory/Cardiac Evaluation

Oxygenation Assessment

• Pulse oximetry to evaluate oxygen saturation
• Arterial blood gas if hypoxemia is suspected or oxygen saturation is low

Chest Imaging

• Chest X-ray to evaluate for:

  • Pneumonia or other pulmonary infections
  • Pulmonary edema (if cardiac etiology is suspected)
  • Other causes of dyspnea 4

• Consider CT pulmonary angiogram if pulmonary embolism is suspected based on risk factors and clinical presentation

Medication-Related Evaluation

Drug Levels and Toxicology

• Consider escitalopram level if toxicity is suspected

  • Escitalopram can cause somnolence, dizziness, and rarely seizures in overdose 5
  • Symptoms may be consistent with serotonin syndrome (agitation, confusion, autonomic instability)

• Comprehensive toxicology screen to evaluate for other substances that may contribute to symptoms

Cardiovascular Assessment

Cardiac Evaluation

• 12-lead ECG to evaluate for:

  • Arrhythmias
  • QT prolongation (known effect of escitalopram)
  • Signs of acute coronary syndrome or other cardiac pathology

• Consider troponin levels to rule out cardiac causes of dyspnea, especially in older patients where ACS may present atypically 1

Special Considerations for Elderly Patients

In patients >75 years of age:

• ACS should be considered when accompanying symptoms include shortness of breath, syncope, or when an unexplained fall has occurred 1
• Falls in elderly patients require comprehensive evaluation as they may be due to syncope, and patients may not be aware of having lost consciousness 1
• Escitalopram has been associated with urinary symptoms in older adults (9.4% in clinical trials) 6

Diagnostic Algorithm

1. Immediate stabilization (ABCs, vital signs)
2. Non-contrast head CT to rule out intracranial pathology
3. Laboratory studies:
   • Complete blood count
   • Basic metabolic panel
   • Urinalysis and culture
   • Consider escitalopram level if toxicity suspected
4. Chest X-ray to evaluate shortness of breath
5. ECG to assess cardiac function and rule out arrhythmias
6. Consider advanced imaging (brain MRI, CT pulmonary angiogram) based on initial findings

Common Pitfalls to Avoid

• Failing to consider medication effects: Escitalopram can cause somnolence, dizziness, and urinary retention 3, 2
• Attributing all symptoms to a single cause: Multiple pathologies may coexist, especially in elderly patients
• Overlooking atypical presentations: Elderly patients may present with falls or altered mental status rather than classic symptoms of infection or cardiac disease 1
• Missing neurological causes: Seizures can be mistaken for falls, especially in patients taking medications that may lower seizure threshold 1

By systematically addressing all presenting symptoms with appropriate diagnostic testing, the underlying cause(s) can be identified and appropriate treatment initiated promptly.