What is the best course of action for a 45-year-old male with a history of Hypertension (HTN) and Diabetes Mellitus (DM), presenting with sudden agitation, decreased attention, and cognitive decline for one day, while on atorvastatin, aspirin, Angiotensin-Converting Enzyme Inhibitor (ACEI), and statin, with normal vitals including blood pressure?

Acute Cognitive Decline and Agitation in a 45-Year-Old with HTN and DM

This patient requires immediate evaluation for delirium with EEG and comprehensive workup to identify reversible causes, not antipsychotics or medication adjustment, as sudden onset cognitive decline with agitation in a middle-aged patient with normal vitals suggests an acute encephalopathy requiring urgent investigation.

Immediate Diagnostic Priority: Rule Out Delirium and Acute Encephalopathy

The clinical presentation—sudden onset (one day) of agitation, decreased attention, and cognitive decline—is the hallmark of delirium, not dementia or medication side effects 1. The key distinguishing features are:

• Acute onset (hours to days) versus insidious onset in dementia 1
• Fluctuating course with disordered attention and consciousness 1
• Normal vital signs do not exclude serious pathology—metabolic encephalopathy, infection, or stroke can present with normal BP and stable vitals initially 1

Why EEG is the Correct Answer

EEG should be performed to evaluate for non-convulsive seizures and encephalopathy patterns, which can present as acute behavioral changes without obvious seizure activity 1. In a 45-year-old with diabetes and hypertension, sudden cognitive decline warrants investigation for:

• Metabolic encephalopathy (hypoglycemia, hyperglycemia, electrolyte disturbances) 1
• Infections (UTI, pneumonia—most common causes) 1
• Cerebrovascular events (stroke, TIA) despite normal BP 1
• Non-convulsive status epilepticus 1

Why NOT the Other Options

B. Medication-Induced Symptoms: Unlikely

The patient's medications (atorvastatin, aspirin, ACEI, statin) are not typically associated with acute agitation or cognitive decline 2. While atorvastatin can rarely cause cognitive impairment, these reports describe:

• Gradual onset (1 day to years), not acute 2
• Nonserious and reversible upon discontinuation 2
• Variable presentation, not the acute delirium pattern seen here 2

ACE inhibitors and aspirin do not cause acute behavioral changes 1. Attributing this to medications without investigation would miss life-threatening conditions.

C. Antipsychotics: Premature and Dangerous

Antipsychotics should never be first-line for acute agitation without identifying the underlying cause 1, 3. In this case:

• No workup has been completed to rule out reversible causes 1
• Antipsychotics can worsen delirium if the cause is metabolic or infectious 1
• Increased mortality risk in patients with underlying medical conditions 3, 4
• Haloperidol is only recommended when behavioral interventions fail AND the patient is severely agitated with imminent risk of harm 1, 4

D. Pelvic Ultrasound: Irrelevant

Pelvic ultrasound has no role in evaluating acute cognitive decline and agitation in a male patient. This is a distractor option with no clinical relevance to the presentation.

Comprehensive Diagnostic Workup Required

Beyond EEG, the following must be systematically evaluated 1:

Laboratory Studies

• Glucose (hypo/hyperglycemia in diabetic patient) 1
• Electrolytes, BUN, creatinine (metabolic derangements) 1
• Complete blood count (infection, anemia) 1
• Urinalysis and culture (UTI—most common infection causing delirium) 1
• Liver function tests (hepatic encephalopathy) 1
• Thyroid function (thyroid storm, myxedema) 1

Imaging

• Head CT or MRI to exclude stroke, hemorrhage, or structural lesions 1, 5
• Chest X-ray if pneumonia suspected 1

Medication Review

• Review for anticholinergic medications that worsen confusion 1, 4
• Assess for drug-drug interactions 2

Management Algorithm After Diagnosis

If Delirium Confirmed

1. Treat underlying cause aggressively (antibiotics for infection, glucose correction, etc.) 1
2. Non-pharmacological interventions first 1, 3:
   • Quiet environment with adequate lighting 1
   • Frequent reorientation 1
   • Minimize invasive procedures 1
   • Ensure sensory aids (glasses, hearing aids) 1
3. Pharmacological intervention ONLY if 1, 3, 4:
   • Severely agitated with imminent risk of harm to self or others
   • Behavioral interventions have failed
   • Haloperidol 0.5-1 mg (maximum 5 mg daily in this age group) 1, 4
   • Avoid benzodiazepines unless alcohol/benzodiazepine withdrawal 1

If Seizure Activity Identified

• Initiate antiepileptic therapy (phenytoin, levetiracetam) 5
• Continuous EEG monitoring if non-convulsive status epilepticus 5

Critical Pitfalls to Avoid

• Never assume "medication side effect" without thorough workup—this delays diagnosis of life-threatening conditions 1
• Never start antipsychotics empirically for acute behavioral changes without identifying the cause 1, 3, 4
• Never overlook infections in diabetic patients—they are at higher risk for UTI and pneumonia 1
• Never assume normal vitals exclude serious pathology—metabolic encephalopathy and early stroke can present with stable vital signs 1, 5

The correct answer is A: EEG, as part of a comprehensive evaluation for acute delirium and encephalopathy, which is the only appropriate approach to sudden cognitive decline and agitation in this clinical context.