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A 52 year-old man with total knee replacement
Get your assignment done
A 52 year-old man becomes confused POD#1 after elective right total knee replacement. The surgery
was performed for degenerative joint disease and went smoothly, without complications. The
anesthesiologistʼs and surgeonʼs post-operative notes describe the patient as alert and fully oriented, as
did the nurseʼs notes the afternoon after his surgery. Late that evening the nurses found him irritable and
somewhat shaky. By the next night, he was tachycardic and intermittently confused. He takes
hydrochlorothiazide for hypertension, but has no other known medical problems. He is a business
executive who travels extensively for work. Other than postoperative antibiotics and patient-controlled
anesthesia, his only medications are hydrochlorothiazide, enoxaparin, and docusate. His preoperative
labs are notable only for a slightly elevated mean corpuscular volume. On examination, his temperature
is 37.7 C, pulse 110 (regular), BP 150/95, RR 16, with O2 sat 98% on room air. He is breathing
comfortably, mildy diaphoretic, and oriented to name, hospital, year and month, but not the date or day of
the week.
He is irritable, refusing to answer some questions and allowing limited examination. General
exam is unremarkable, except for an intact, dry dressing and brace on the right leg. Pupils are 8mm and
reactive, EOMs are full without nystagmus, and there is no pronator drift, although he is tremulous.
Reflexes in the arms and at the left knee are brisk with an absent ankle reflex and flexor plantar
response on the left; the right leg is untestable because of his surgery.
A 52 year-old man with total knee replacement. (Get your assignment done)
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?