Lying Low

A CLINICAL PROBLEM-SOLVING article by Anand Vaidya from Brigham and Women's Hospital, Boston.
An 88-year-old woman presented to the emergency room with confusion.
Her symptoms had begun 1 year earlier, with episodes of transient confusion, dizziness, tremors, and anxiety. These episodes occurred unpredictably, were unrelated to eating or physical activity, lasted for minutes before gradual recovery, and had increased in frequency over the year. She felt well between episodes. In addition, she described spells of double vision that were of sudden onset and often independent of her other symptoms.
The patient's medical history included myocardial infarction, hypertension, hypercholesterolemia, mild chronic renal insufficiency, and benign colonic polyps.
On physical examination, the patient appeared well and was no longer confused. The vital signs and examination were unremarkable. Routine laboratory tests, echocardiographic findings and CT of the head were normal. The patient remained asymptomatic and was discharged home with a plan for outpatient follow-up.
2 months after discharge, a close friend witnessed the patient in her home, standing with a blank stare and not responding when her friend spoke to her. When confronted, the patient appeared startled; she ran, tripped, and fell to the floor, after which she was minimally responsive. She was taken to the emergency room and was asymptomatic on arrival.
An interactive medical case related to this case is available at NEJM.org. [Original Article]