What is the appropriate diagnostic approach for a patient with a history of spinal stenosis, asthma (Adthma), hypertension (HTN), diabetes mellitus type 2 (DM2), and osteomyelitis, presenting with prolonged QT interval, nausea and vomiting (NV), and colitis, after a fall onto their knees without head trauma, now exhibiting confusion and combativeness?

From the Guidelines

I strongly recommend ordering a non-contrast CT scan of the head for this patient. Although the patient reportedly did not hit their head during the fall, their current confusion and combative behavior are concerning for a possible intracranial process that requires immediate evaluation, as suggested by the guidelines for geriatric emergency department management 1. Non-contrast CT is preferred over contrast-enhanced CT in this emergency situation as it can quickly identify acute hemorrhage, mass effect, or other structural abnormalities that might explain the patient's altered mental status. Given the patient's history of diabetes, hypertension, and prolonged QT interval, they are at increased risk for stroke and other neurological complications, which is a concern in patients with prolonged QT intervals 1. The patient's confusion could also represent a post-ictal state, metabolic derangement, or medication effect, but a head CT is an appropriate first diagnostic step to rule out acute intracranial pathology, as recommended for patients with ataxia or suspected intracranial injury 1.

Some key points to consider in this patient's management include:

• The patient's prolonged QT interval, which increases their risk for arrhythmias and other cardiac complications 1
• The patient's history of spinal stenosis, which may increase their risk for spinal injury or exacerbation of existing spinal conditions
• The patient's history of osteomyelitis, which may increase their risk for infection or sepsis
• The patient's current confusion and combative behavior, which require immediate evaluation and management to prevent further injury or complications

After obtaining the CT, further workup including laboratory studies to assess for metabolic causes of confusion would be warranted, as well as consideration of other potential causes of the patient's symptoms, such as infection or medication effects. The use of imaging modalities such as CT or MRI may be helpful in evaluating the patient's spine or other areas of suspected pathology, as recommended for patients with suspected osteomyelitis or septic arthritis 1.

From the Research

Patient Assessment

The patient, Dunn Mary Therese, has a history of spinal stenosis, asthma, hypertension, diabetes mellitus type 2, and osteomyelitis. The patient recently experienced a fall, landing on their knees without hitting their head, and is now presenting with confusion and combativeness.

Diagnostic Considerations

• The patient's prolonged QT interval is a significant concern, as it can increase the risk of malignant arrhythmias and sudden cardiac death 2, 3, 4, 5.
• The patient's confusion and combativeness may be related to their fall, but it is also possible that they are experiencing a cardiac-related event, such as syncope or seizures, which are common presentations of long QT syndrome 2, 3.
• A CT head scan with or without contrast may be necessary to rule out any head injuries or other causes of the patient's confusion and combativeness 6.

Treatment Options

• The patient's long QT syndrome should be managed with lifestyle modifications, beta-blockers, and possibly implantable defibrillators to reduce the risk of sudden cardiac death 2, 3, 4.
• The patient's confusion and combativeness should be addressed with appropriate medical treatment, which may include CT scans, laboratory tests, and other diagnostic procedures to determine the underlying cause of their symptoms 6.