What is the appropriate diagnosis and management for an elderly patient presenting with coffee-ground vomiting, lower back pain radiating to the right leg, bilateral lower extremity weakness, urinary incontinence, productive cough, and rhythmic jerking of arms?

Clinical Teaching Case: Multisystem Presentation in an Elderly Patient

Presentation and Investigation

An elderly patient presented to the emergency department with a complex constellation of symptoms spanning multiple organ systems. The chief complaints included coffee-ground vomiting occurring multiple times daily for 5 days, suggesting upper gastrointestinal pathology 1. Concurrently, the patient reported lower back pain radiating to the right leg with bilateral lower extremity weakness and rigidity, accompanied by urinary incontinence and decreased sensation—symptoms present for 2 weeks that raise immediate concern for cauda equina syndrome 2, 3. Additional complaints included a productive cough for 5 days and rhythmic jerking movements of the arms that were action-induced, resolved with restraint, and occurred without loss of consciousness. The patient also reported constipation for 1 week 4.

Previous neuroimaging (brain MRI) had revealed a small right vestibular schwannoma with microhemorrhage, mild-to-moderate global cerebral atrophy, and mild chronic small-vessel ischemic changes.

Physical examination findings were notable for:

• Vital signs: Blood pressure 100/60 mmHg (low-normal), heart rate 83 bpm, respiratory rate 23 breaths/min (tachypneic), temperature 36.1°C (afebrile), and oxygen saturation 92% on room air (hypoxemic) 4
• Abdominal examination: Distended abdomen without tenderness; rectal examination revealed impacted stool 4
• Neurological examination: Glasgow Coma Scale 15/15, motor strength 5/5 in upper extremities and left lower extremity, but 4/5 in the right lower extremity 2, 3
• HEENT, chest, and cardiac examinations were unremarkable

Laboratory investigations revealed:

• Anemia: Hemoglobin 10.6 g/dL, hematocrit 33% 1, 5
• Leukocytosis with neutrophilia: Neutrophils 86.5% (elevated), lymphocytes 6.5% (decreased) 4
• Hypokalemia: Potassium 3.16 mEq/L 4
• Elevated inflammatory markers: CRP 20 mg/L 4
• Renal dysfunction: Creatinine 1.03 mg/dL (elevated), urea 95.1 mg/dL (elevated) 4
• Mild transaminitis: ALT 40.9 U/L, AST 45 U/L, alkaline phosphatase 103 U/L 4
• Normal coagulation profile and thyroid function

Echocardiography demonstrated grade I/II diastolic dysfunction with mild aortic regurgitation and preserved systolic function.

Problem List

1. Coffee-ground vomiting with anemia (suspected upper gastrointestinal bleeding)
2. Lower back pain with radiculopathy, bilateral lower extremity weakness, urinary incontinence, and decreased sensation (red flags for cauda equina syndrome)
3. Productive cough with hypoxemia (SpO₂ 92%) and tachypnea (suspected pneumonia)
4. Rhythmic jerking movements of arms (action-induced, non-epileptic)
5. Severe constipation with fecal impaction
6. Hypokalemia
7. Leukocytosis with neutrophilia and elevated CRP
8. Acute kidney injury with azotemia
9. Hypotension (BP 100/60 mmHg)
10. Known vestibular schwannoma with microhemorrhage

Interpretation

Coffee-Ground Vomiting and Anemia

Coffee-ground emesis classically suggests upper gastrointestinal bleeding, where gastric acid converts hemoglobin to hematin, producing the characteristic appearance 1. However, recent evidence challenges the assumption that coffee-ground vomiting always indicates significant bleeding. A large database study found that patients with coffee-ground vomiting alone had significantly lower endoscopic yield for high-risk lesions (gastric ulcer, duodenal ulcer, varices, malignancy) compared to those with frank hematemesis or melena 5. In this cohort, coffee-ground vomiting was more commonly associated with esophagitis or no identifiable source, with lower rates of blood transfusion requirement and rebleeding 5.

In this patient, the hemoglobin of 10.6 g/dL represents mild anemia but is relatively stable (no documented drop), and the patient is hemodynamically stable 1, 5. The coffee-ground vomiting may represent a less urgent gastrointestinal process or could be secondary to other systemic illnesses. Critically, hemodynamically stable patients with coffee-ground aspirate should be evaluated for non-GI bleeding-related conditions even as the GI bleed is being managed 1.

Lower Back Pain with Neurological Red Flags

This is the most urgent problem requiring immediate attention. The constellation of lower back pain radiating to the leg, bilateral lower extremity weakness, urinary incontinence, and decreased sensation constitutes classic red flags for cauda equina syndrome (CES) 2, 3, 6. CES results from compression of the lumbosacral nerve roots (cauda equina) and represents a true surgical emergency 2, 6.

Pathophysiology: CES typically results from a large space-occupying lesion within the lumbosacral spinal canal causing direct mechanical compression, venous congestion, or ischemia of nerve roots 2. Common causes include massive disc herniation (most common), spinal stenosis, tumors, trauma, or epidural abscess/hematoma 2, 6.

Clinical presentation: The classic syndrome includes urinary retention (most sensitive finding), saddle anesthesia of the perineum, bilateral lower extremity pain/numbness/weakness, and decreased rectal tone 2, 6. However, CES can present insidiously with subtle initial symptoms that may be mistaken for lumbar radiculopathy, spinal stenosis, or urinary tract disorders 3. This patient demonstrates several cardinal features: bilateral leg involvement (right leg radiculopathy with right leg weakness 4/5), urinary incontinence (which may represent overflow from retention), and decreased sensation 2, 3.

Critical timing: Early diagnosis is challenging because initial signs are often subtle 2. Delayed recognition beyond 48 hours of symptom onset is associated with irreversible neurological deficits including permanent bladder/bowel dysfunction and lower extremity paralysis, even with surgical intervention 2, 3, 6. This patient has had symptoms for 2 weeks, placing them at extremely high risk for permanent disability.

Differential considerations: While the 2-week duration might suggest a more chronic process, CES can develop gradually 3. The unilateral motor weakness (right leg 4/5) does not exclude CES, as asymmetric presentations are common early in the syndrome 3, 6.

Productive Cough with Hypoxemia

The combination of productive cough, hypoxemia (SpO₂ 92%), tachypnea (RR 23), leukocytosis with neutrophilia, and elevated CRP strongly suggests community-acquired pneumonia (CAP) 4. In elderly patients, pneumonia often presents with atypical features and carries significant mortality risk 4.

Clinical significance: Hypoxemia (SpO₂ <90%) is a critical indicator of acute severity and short-term mortality in pneumonia and predicts impending respiratory failure 4. This patient's SpO₂ of 92% places them in a moderate-risk category. The elevated neutrophil count (86.5%) with lymphopenia (6.5%) and elevated CRP (20 mg/L) support bacterial infection 4.

Elderly-specific considerations: Older adults with infections frequently present with nonspecific symptoms such as confusion, functional decline, or falls rather than classic fever and cough 4, 7. This patient is afebrile (36.1°C), which is common in elderly bacteremia and pneumonia—approximately 15% of older persons with bacteremia are afebrile 4. The absence of fever should not delay diagnosis or treatment 4.

Diagnostic approach: Chest radiography demonstrating a new infiltrate is the most reliable diagnostic method for pneumonia in long-term care and elderly populations 4. Pulse oximetry confirming SpO₂ <90% indicates need for intensive monitoring 4.

Rhythmic Jerking Movements

The action-induced rhythmic jerking of arms that resolves with restraint and occurs without loss of consciousness does not fit epileptic seizure activity. This likely represents myoclonus, tremor, or a movement disorder rather than a primary neurological emergency. Given the patient's known cerebral atrophy and small-vessel ischemic changes, this could represent cortical myoclonus or essential tremor exacerbated by metabolic derangements (hypokalemia, uremia) 4. The clonazepam prescribed (0.25 mg daily) is appropriate for myoclonus but requires careful monitoring in elderly patients.

Severe Constipation with Fecal Impaction

Fecal impaction found on rectal examination, combined with 1 week of constipation, is clinically significant for multiple reasons 4:

1. Can cause or exacerbate urinary retention/incontinence (mimicking or masking CES symptoms)
2. May contribute to abdominal distension and discomfort
3. Can cause bowel obstruction if severe 4
4. Common in elderly patients with reduced mobility and neurological conditions

The bisacodyl prescribed is appropriate initial management 4.

Hypokalemia

Potassium 3.16 mEq/L is mild hypokalemia likely secondary to poor oral intake (5 days of vomiting), renal losses, or redistribution 4. Hypokalemia can exacerbate cardiac arrhythmias (relevant given diastolic dysfunction and aortic regurgitation) and contribute to weakness and ileus 4.

Leukocytosis and Elevated Inflammatory Markers

Neutrophilia (86.5%) with lymphopenia (6.5%) and elevated CRP (20 mg/L) indicate acute bacterial infection 4. In elderly patients, this pattern is most consistent with pneumonia or urosepsis 4. The absence of high fever does not exclude serious infection in this age group 4.

Acute Kidney Injury

Elevated creatinine (1.03 mg/dL) and markedly elevated urea (95.1 mg/dL) with a high BUN:creatinine ratio suggest prerenal azotemia from dehydration (5 days of vomiting, poor intake, positive fluid balance of +1500 mL suggesting third-spacing or inadequate resuscitation) 4. However, in the context of urinary incontinence and possible urinary retention (CES), post-renal obstruction must be excluded 4, 2.

Hypotension

Blood pressure 100/60 mmHg is low-normal but concerning in the context of possible sepsis (pneumonia or urosepsis), dehydration, or gastrointestinal bleeding 4. Elderly patients with bacteremia and hypotension have significantly increased mortality 4.

Diagnosis

Primary Diagnoses (in order of urgency):

1. Suspected Cauda Equina Syndrome (MOST URGENT)

This is a neurosurgical emergency requiring immediate MRI of the lumbosacral spine and urgent surgical consultation 2, 3, 6. The patient demonstrates multiple red-flag features: lower back pain with leg radiation, bilateral lower extremity involvement (right leg weakness 4/5, bilateral rigidity), urinary incontinence, and decreased sensation present for 2 weeks 2, 3, 6. While the 2-week duration suggests delayed presentation, CES can develop insidiously and surgical decompression may still provide benefit, though permanent deficits are likely given the prolonged compression 2, 3, 6.

Differential considerations:

• Lumbar spinal stenosis: Can cause bilateral leg symptoms but typically lacks acute urinary dysfunction 3
• Conus medullaris syndrome: Similar presentation but involves upper motor neuron signs; differentiation requires imaging 6
• Epidural abscess/hematoma: Less likely without fever, trauma, or anticoagulation, but must be excluded 2
• Metastatic spinal cord compression: Possible given age, but no known primary malignancy

Diagnostic confirmation: Urgent MRI of the lumbosacral spine is mandatory to identify the compressive lesion and guide surgical planning 2, 3, 6. This takes absolute priority over endoscopy or other investigations.

2. Community-Acquired Pneumonia

The combination of productive cough, hypoxemia (SpO₂ 92%), tachypnea (RR 23), leukocytosis with neutrophilia (86.5%), and elevated CRP (20 mg/L) establishes a clinical diagnosis of pneumonia 4. The patient meets criteria for moderate-severity CAP requiring hospitalization based on hypoxemia and tachypnea 4.

Diagnostic confirmation: Chest radiography should be obtained to confirm infiltrate and assess severity 4. Blood cultures should be drawn given the leukocytosis and risk of bacteremia (urinary tract is the most common source of bacteremia in elderly, followed by respiratory tract at 10-11%) 4.

3. Upper Gastrointestinal Process (likely non-bleeding)

While coffee-ground vomiting suggests upper GI pathology, the hemodynamic stability, stable hemoglobin, and absence of melena or frank hematemesis make significant active bleeding less likely 1, 5. Coffee-ground vomiting in stable patients is more commonly associated with esophagitis, gastritis, or non-bleeding causes 5. However, peptic ulcer disease, gastritis, or esophagitis remain on the differential and warrant investigation once life-threatening conditions are addressed 1, 5.

Differential considerations:

• Esophagitis/gastritis: Most likely given stable hemodynamics 5
• Peptic ulcer disease: Possible but would expect more significant anemia or hemodynamic changes 1
• Mallory-Weiss tear: Less likely with coffee-ground (rather than bright red) emesis 5
• Gastric malignancy: Must be excluded in elderly patient with weight loss history

4. Urinary Tract Infection (possible, requires confirmation)

Urinary incontinence in an elderly patient with leukocytosis and elevated inflammatory markers raises concern for urosepsis 4. However, urinary symptoms in this patient may be entirely explained by cauda equina syndrome 2, 3. In elderly patients, asymptomatic bacteriuria is extremely common (10-50% prevalence) and should not be treated 4.

Diagnostic approach: Urinalysis and urine culture should be obtained, but treatment should only be initiated if there are specific urinary symptoms (dysuria, frequency, urgency, suprapubic pain) or systemic signs of urosepsis (fever, hypotension, altered mental status) 4, 8. The absence of pyuria or negative leukocyte esterase/nitrite on dipstick can help exclude UTI 4.

Critical caveat: In this patient, urinary incontinence is more likely a neurological symptom of CES rather than a UTI symptom 2, 3. Treating presumed UTI without addressing the underlying neurological emergency would be a catastrophic error.

5. Fecal Impaction with Severe Constipation

Confirmed by rectal examination 4. This is a common problem in elderly patients with reduced mobility and can contribute to urinary symptoms and abdominal distension 4.

6. Prerenal Acute Kidney Injury

Elevated BUN (95.1 mg/dL) and creatinine (1.03 mg/dL) with high BUN:creatinine ratio indicate prerenal azotemia from dehydration 4. However, post-renal obstruction from urinary retention (CES) must be excluded with bladder ultrasound or post-void residual measurement 2.

7. Hypokalemia

Mild hypokalemia (3.16 mEq/L) secondary to vomiting and poor intake 4.

8. Movement Disorder (likely myoclonus)

Action-induced rhythmic jerking without loss of consciousness, likely related to underlying cerebral pathology and metabolic derangements 4.

Management

Current Management (Critical Appraisal):

1. IV Fluids (Normal Saline 1L + Dextrose 3×40%, IV BID)

Appropriate for addressing prerenal azotemia and dehydration from 5 days of vomiting 4. The addition of dextrose is reasonable given NPO status. However, the positive fluid balance of +1500 mL with urine output of only 500 mL raises concern for urinary retention (possible CES manifestation) or inadequate renal perfusion 2. Bladder ultrasound or catheterization to measure post-void residual is urgently needed 2, 3.

2. Omeprazole (80 mg IV stat, then 40 mg IV BID)

Appropriate for suspected upper GI bleeding, though likely excessive given the stable presentation 1, 5. High-dose IV PPI (80 mg bolus followed by continuous infusion or 40 mg BID) is guideline-recommended for peptic ulcer bleeding, but this patient's coffee-ground vomiting without hemodynamic instability or significant anemia suggests lower-risk pathology 5. Standard-dose PPI (40 mg daily) would likely suffice, but the current regimen is not harmful.

3. Clonazepam (0.25 mg PO daily)

Reasonable for myoclonus or tremor, but requires caution in elderly patients due to fall risk, cognitive impairment, and respiratory depression (especially concerning given hypoxemia) 4. The low dose (0.25 mg) is appropriate for initiation.

4. Bisacodyl (5 mg PO daily)

Appropriate for fecal impaction and constipation 4. However, manual disimpaction may be needed first, followed by more aggressive bowel regimen (higher-dose laxatives, enemas) 4.

5. Metoclopramide (10 mg IV TID)

Appropriate as antiemetic for vomiting 4. However, metoclopramide carries risk of extrapyramidal side effects in elderly patients and may worsen the rhythmic jerking movements. Alternative antiemetics (ondansetron) should be considered 4.

6. NPO Status

Appropriate given active vomiting and planned investigations (endoscopy, possible surgery) 1.

Critical Missing Management Steps:

IMMEDIATE (within 1-2 hours):

1. URGENT MRI of Lumbosacral Spine

This is the absolute priority and must be obtained immediately 2, 3, 6. The patient has red-flag symptoms for cauda equina syndrome present for 2 weeks—every hour of delay increases the risk of permanent neurological disability 2, 3. If MRI is unavailable or contraindicated, CT myelography is an alternative 2.

Action: Contact radiology immediately for stat MRI lumbar spine. Simultaneously contact neurosurgery or orthopedic spine surgery for urgent consultation 2, 3, 6.

2. Neurosurgical/Spine Surgery Consultation

Urgent surgical decompression is the definitive treatment for CES 2, 3, 6. Consultation should occur simultaneously with imaging, not after, to minimize time to operating room 2, 6.

3. Bladder Ultrasound or Urethral Catheterization

Assess for urinary retention (post-void residual >200-300 mL confirms retention) 2, 3. This is both diagnostic (confirms CES) and therapeutic (prevents bladder overdistension and renal damage) 2. The low urine output (500 mL over 24 hours) despite 2000 mL IV intake strongly suggests retention 2.

4. Chest Radiograph (Portable)

Confirm pneumonia diagnosis and assess severity 4. Given hypoxemia and tachypnea, this should be obtained urgently 4.

5. Blood Cultures (×2 sets from separate sites)

Obtain before antibiotics to identify bacteremia, which occurs in ~6% of LTCF-acquired infections and carries 20-35% mortality 4. The urinary tract accounts for 50-55% of bacteremias in elderly, followed by respiratory tract (10-11%) 4.

6. Urinalysis and Urine Culture

Obtain to evaluate for UTI, but interpret cautiously given high prevalence of asymptomatic bacteriuria in elderly 4. Negative leukocyte esterase and nitrite can help exclude UTI 4. However, do not delay CES workup or treatment for UTI evaluation 2.

URGENT (within 4-6 hours):

7. Empiric Antibiotic Therapy for Pneumonia

Start immediately after blood cultures are drawn 4. For community-acquired pneumonia in an elderly patient with moderate severity (hypoxemia, tachypnea), guideline-recommended regimens include:

• Beta-lactam (ceftriaxone 1-2 g IV daily or ampicillin-sulbactam 1.5-3 g IV q6h) PLUS macrolide (azithromycin 500 mg IV daily), OR
• Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg IV daily or moxifloxacin 400 mg IV daily) 4

Preferred regimen: Ceftriaxone 1 g IV daily + azithromycin 500 mg IV daily, as this provides broad coverage for typical and atypical pathogens while minimizing fluoroquinolone use (which carries FDA warnings for disabling adverse effects in elderly) 8.

8. Supplemental Oxygen

Maintain SpO₂ >90% (target 92-96%) 4. Start with nasal cannula 2-4 L/min and titrate to maintain adequate oxygenation 4.

9. Potassium Replacement

Correct hypokalemia to prevent cardiac arrhythmias and weakness 4. Add potassium chloride 20-40 mEq to IV fluids or give oral supplementation if tolerating PO 4.

SEMI-URGENT (within 24 hours):

10. Upper Endoscopy (EGD)

Defer until after CES and pneumonia are addressed, as the patient is hemodynamically stable with stable hemoglobin 1, 5. If the patient requires emergency surgery for CES, endoscopy can be performed during the same anesthetic if clinically indicated 1. Given the low yield of coffee-ground vomiting for high-risk lesions, endoscopy may ultimately not be necessary if symptoms resolve with PPI therapy 5.

11. Manual Disimpaction and Aggressive Bowel Regimen

Address fecal impaction with manual disimpaction (if not contraindicated by thrombocytopenia or coagulopathy), followed by enemas (sodium phosphate or mineral oil) and escalated oral laxatives (polyethylene glycol, senna) 4. Fecal impaction can contribute to urinary retention and must be relieved 4.

12. Echocardiography Review

Already completed, showing diastolic dysfunction and mild aortic regurgitation. This informs fluid management (avoid overload) and antibiotic selection (consider endocarditis prophylaxis if invasive procedures planned, though not routinely indicated for GI endoscopy).

13. Nutrition Assessment

Once acute issues stabilized, assess nutritional status and consider enteral nutrition if prolonged NPO anticipated 4.

Monitoring and Supportive Care:

1. Continuous Monitoring

• Vital signs every 2-4 hours (more frequently if unstable) 4
• Continuous pulse oximetry given hypoxemia 4
• Strict intake/output monitoring (especially urine output to assess renal function and retention) 4, 2
• Serial neurological examinations (motor strength, sensation, rectal tone) to detect progression of CES 2, 3

2. Venous Thromboembolism Prophylaxis

• Mechanical prophylaxis (sequential compression devices) given bleeding risk from possible GI source 4
• Consider pharmacologic prophylaxis (low-dose heparin or enoxaparin) once GI bleeding risk clarified 4

3. Fall Precautions

• High fall risk due to lower extremity weakness, clonazepam use, and hypotension 4

4. Delirium Prevention

• Elderly patients with infections are at high risk for delirium 4, 7
• Minimize sedating medications, maintain day-night orientation, early mobilization (once neurologically safe) 4, 7

Definitive Management Algorithm:

STEP 1: STAT MRI lumbar spine + neurosurgery consult (if CES confirmed → urgent surgical decompression within hours) 2, 3, 6

STEP 2: Bladder catheterization (assess retention, prevent renal damage) 2, 3

STEP 3: Chest X-ray + blood cultures + start antibiotics for pneumonia (ceftriaxone + azithromycin) 4

STEP 4: Urinalysis/culture (treat UTI only if symptomatic or septic) 4, 8

STEP 5: Continue supportive care (IV fluids, PPI, oxygen, electrolyte repletion, bowel regimen) 4

STEP 6: Endoscopy (defer until after surgery/stabilization, may not be needed) 1, 5

STEP 7: Rehabilitation (physical therapy, bladder/bowel retraining post-CES surgery) 2, 3

Learning Points

1. Cauda Equina Syndrome Recognition

• Lower back pain + leg weakness + urinary dysfunction = neurosurgical emergency requiring MRI and decompression within hours 2, 3, 6
• CES can present insidiously over days to weeks; high index of suspicion is critical 3, 6
• Delayed diagnosis beyond 48 hours results in irreversible neurological deficits in most patients 2, 3, 6
• Urinary retention (not incontinence) is the most sensitive finding; check post-void residual in all suspected cases 2, 3

2. Atypical Presentations in Elderly Patients

• Elderly patients with serious infections (pneumonia, bacteremia) frequently present without fever (15% of bacteremic elderly are afebrile) 4
• Nonspecific symptoms (confusion, falls, functional decline, incontinence) may be the only manifestations of infection 4, 7
• Absence of classic symptoms should not delay diagnosis or treatment of life-threatening conditions 4

3. Coffee-Ground Vomiting Interpretation

• Coffee-ground emesis in hemodynamically stable patients has low yield for high-risk GI lesions and may not require urgent endoscopy 5
• Stable patients with coffee-ground vomiting should be evaluated for non-GI causes (infection, cardiac, renal) that may be more clinically significant 1
• High-dose PPI is appropriate initial therapy, but endoscopy can be deferred if patient stabilizes 1, 5

4. Pneumonia in Elderly: Severity Assessment

• Hypoxemia (SpO₂ <90%) and tachypnea (RR >25) are critical predictors of mortality and need for ICU admission 4
• Pulse oximetry is essential for bedside assessment of pneumonia severity 4
• Empiric antibiotics should cover typical and atypical pathogens; avoid fluoroquinolones as first-line due to adverse effects 8

5. Urinary Tract Infection Diagnosis in Elderly

• Asymptomatic bacteriuria is present in 10-50% of elderly and should NOT be treated 4
• Pyuria and positive urine culture do not confirm UTI in the absence of specific urinary symptoms 4
• Nonspecific symptoms (confusion, incontinence) are not reliable indicators of UTI and may represent other serious conditions 4, 7
• Negative leukocyte esterase and nitrite on dipstick can help exclude UTI 4

6. Prioritization in Complex Multisystem Cases

• Life-threatening conditions (CES, sepsis) take absolute priority over less urgent problems (stable GI bleeding, constipation) 2, 3, 6
• Systematic approach: Airway/Breathing/Circulation → Neurological emergencies → Infections → Other problems 4, 2
• Avoid anchoring bias (assuming vomiting = GI problem) when red-flag symptoms suggest alternative diagnoses 2, 1

7. Bacteremia Risk in Elderly

• Urinary tract (50-55%) and respiratory tract (10-11%) are the most common sources of bacteremia in elderly 4
• Mortality from bacteremia in elderly is 20-35% overall, 50% for bacteremic pneumonia 4
• Blood cultures should be obtained in elderly patients with leukocytosis, hypotension, or severe infection before starting antibiotics 4

8. Medication Safety in Elderly

• Benzodiazepines (clonazepam) increase fall risk and respiratory depression; use lowest effective dose 4
• Metoclopramide can cause extrapyramidal symptoms; consider alternatives (ondansetron) 4
• Fluoroquinolones carry FDA black box warnings for disabling adverse effects in elderly; avoid as first-line 8

9. Multidisciplinary Care Coordination

• Complex elderly patients require simultaneous management of multiple problems by multiple specialties (neurosurgery, internal medicine, gastroenterology) 4, 2
• Clear communication and prioritization prevent delays in critical interventions 2, 3

10. Prognostic Implications

• This patient's 2-week delay in CES diagnosis likely means permanent neurological deficits despite surgical decompression 2, 3, 6
• Early recognition and treatment within 48 hours of symptom onset offers the best chance for neurological recovery 2, 3, 6
• Pneumonia with hypoxemia in elderly carries significant mortality risk requiring aggressive treatment 4