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A 67-year-old male with a history of hypertension and atrial fibrillation is brought to the emergency department by his daughter, who reports that over the past 48 hours he has become increasingly confused, emotionally labile with episodes of crying without clear provocation, and has been making bizarre statements. She initially thought he was having a psychiatric crisis. On examination, the patient has a flattened right nasolabial fold, subtle right-sided pronator drift, and his speech is fluent but contains occasional paraphasic errors. He is alert but disoriented to date and situation. His vital signs show blood pressure 178/96 mmHg and an irregularly irregular heart rhythm at 92 bpm. A depression screening is attempted but he is unable to reliably complete it due to confusion. Which of the following diagnoses should be prioritized in the immediate workup?
Explanation
Cerebrovascular accidents can present with prominent psychiatric symptoms including acute confusion, emotional lability, and behavioral changes that may initially be mistaken for a primary psychiatric disorder. The PMHNP must recognize lateralizing neurological signs such as facial asymmetry, pronator drift, and paraphasic errors as indicators of stroke requiring emergent evaluation, particularly in patients with vascular risk factors.
Key Takeaway
New-onset psychiatric symptoms in elderly patients with vascular risk factors must be evaluated for cerebrovascular accident, especially when focal neurological findings such as facial asymmetry, pronator drift, or speech abnormalities are present on examination.