Clinical Reasoning: An 81-year-old woman with confusion, weakness, and left-sided hemineglect.

Abstract

An 81-year-old right-handed woman presented to the emergency department (ED) with confusion, generalized weakness, and difficulty ambulating. In addition to several cardiovascular comorbidities (hypertension, hyperlipidemia, peripheral arterial disease, coronary artery disease, chronic kidney disease, and renal artery stenosis), her medical history was significant for stage IV carcinoma of the urinary bladder. She had been in her usual state of health until 1 week prior to her presentation when she began experiencing generalized weakness in her legs, requiring more frequent use of a walker as well as intermittent headaches and increasing forgetfulness. Two to 3 days prior to presentation, her husband noted that she was increasingly getting confused. On the day of presentation, she woke up disoriented and was too weak to get out of bed, prompting her husband to bring her to the ED. In the ED, she was afebrile, hypertensive (180/90 mm Hg), and tachycardic (heart rate 120–130/min). On mental status examination, she was intermittently oriented to time and place and unable to follow complex instructions. Her score on the Montreal Cognitive Assessment (MoCA) was 9/30. Other pertinent examination findings included left facial weakness (lower face) and left upper and lower extremity weakness (3/5). Sensory examination revealed left-sided hemineglect. The patient was unable to ambulate as she could not stand without assistance.