Confusion and chest pain in a 67-year-old paint stripper

A 67-year-old male patient has been brought by his wife and a neighbor to the hospital emergency room on a weekend while you are on call. Complaining of headache and chest pain, he is unable to provide additional information because of his confusion and disorientation. His wife states that he retired 2 years ago and has been relatively vigorous and in good health since. His principal activities have been house repairs and gardening. He was in his usual state of health, including normal mental alertness for his age, until approximately 2 weeks ago.

Over the past 2 weeks, his wife noted progressive loss of mental alertness and increasing fatigue and lethargy, becoming much worse in the evening. He usually sleeps 8 hours a night, but in the past 2 days he has been slow to rise even after 10 hours of sleep. She has noticed that he has become increasingly slow to respond, has slurred speech, and has mood swings from extremely happy to sad or anxious. Yesterday she found him wandering in various rooms of the house and in the yard. Upon questioning, he did not remember why he was in those particular places. He called her a number of times to find tools that he had misplaced, which was unlike him. When she asked him today how he was feeling, for the first time he mentioned having headache and chest pain, but he could not remember when they began.

A review of the history provided by his wife reveals that the patient has mild degenerative arthritis in his fingers and hips, for which he takes an over-the-counter variety of ibuprofen. He was evaluated for occasional chest discomfort at age 55, including a treadmill stress test that his wife believes was negative. At that time, a diagnosis for the chest pain was not determined, and the pain resolved without medication. He was hospitalized in his twenties for an appendectomy. He smoked a pack of cigarettes a day from age 20 to age 55, at which time he quit smoking. They have two children and five grandchildren, all alive and well. His parents have been dead for many years; his wife believes that they had some “heart problems.”

For the past 2 weeks he has been working, as he has often done in the past, on home repairs and in the garden. He has a basement workshop; his wife knows that he has been preparing some furniture for repainting. She states, “My husband and our neighbor spend many hours on projects and like to be left alone.” She believes that he has been working for approximately 2-hour intervals, removing paint from the furniture. He has also been tending to their lawn; he spread fertilizer once 2 weeks ago, and at least once since then has dusted their roses with what she thinks is a fungicide. The garden materials are stored in their basement.

On physical examination, you find a well-nourished, somewhat anxious and disheveled man, appearing his stated age. He is well-tanned and mildly diaphoretic. His blood pressure is 145/80, pulse is 110 and regular, and temperature is normal. He has slurred speech and 15- to 20-second delays in responding to questions. He is oriented only to person, requires concentration for an approximate identification of place, and is disoriented to time. He has little recall of either recent or past events and cannot perform serial numbers. The rest of his physical examination is unremarkable, except for tachycardia with a fourth heart sound. There are no focal neurological findings. An electrocardiogram shows sinus tachycardia and a 1-mm depression of the ST segment in lead V₃. A complete blood count, chemistry panel, arterial blood gases, and urinalysis are within normal limits.

Upon conferring with the emergency physician, you administer sublingual nitroglycerin during electrocardiographic monitoring. The patient reports relief of chest pain, and the ST segment depression returns to normal. You have him admitted to the coronary care unit for observation.

Answers are incorporated in Challenge answers (7) through (9).