An old patient with end stage renal disease and sudden onset of confusion and lethargy

The patient, a 97-year-old Caucasian male, was found in a lethargic and confused condition in his apartment. He was admitted to the emergency room of our hospital. Past medical history included end stage renal disease secondary to hypertension – treated by haemodialysis for the last 5 years, symptomatic bradycardia – treated with a permanent cardiac pacemaker and hypothyroidism. Prescribed medication included levothyroxin, calcitriol, furosemide, captopril, erythropoetin, calciumacetate and iron. According to the patient’s nephrologist, the patient had been well. He did not use alcohol or tobacco. There had been no problems during haemodialysis so far. On physical examination the patient was indeed lethargic and confused. His blood pressure was 150/80mmHg; heart rate was 68 bpm, body temperature 36.58C and respiratory rate 16 breaths per minute. The patient was diaphoretic, the skin turgor was normal and there was no oedema. He had neither neck stiffness nor any paralysis. The cardiac auscultation was unremarkable and breathing sounded normal. There were a few crackles over the base of the left lung. The remainder of the examination was unremarkable. The results of the laboratory evaluation are given in Table 1. Questions