Case #1 Answers:
Mr. Howard has had an acute in mental status with decreased consciousness. Given the findings on neurological examination, the sleepiness, and the history of coumadin use, one must be very concerned about an intracranial bleed, especially the possibility of a sub-dural hematoma.
Mr. Howard needs a CT scan. An MRI would not be as good as the CT scan is the test of choice to detect intracranial bleeding.
The emergent CT scan can be justified by the acute changes and the plan to obtain neurosurgical consultation and drainage if a subdural hematoma is found.