Case 21: Feeling Confused

Mr Harold Vincent is a 81 year old man who has been referred to the acute medical take with dehydration and confusion, after being seen on a home visit by his GP.

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Mr Vincent tells you he isn’t sure why he is in the hospital and how he ended up here. He insists he is well and can’t understand why everyone is fussing over him. When you ask him direct questions about his health, he denies all symptoms. He tells you he works as an accountant and lives with his parents and when you try and ask further questions about his social history, he becomes agitated and asks you to leave.

GP Letter:

Dear Medical Doctor,

Mr Smith’s  son asked me to go and see him urgently at home. I haven’t seen him for a while but he certainly looks like he’s not had much to drink the last few days and appears to be confused and can’t stay at home like this. There’s no history of dementia but when he came to see the practice nurse for a blood pressure check last year she commented he wasn’t as sharp as he had been. 

PMH: Hypertension and Benign Prostatic Hypertrophy

DH: tamsulosin 400mcg, bendroflumethiazide 2.5mg. He has also recently been prescribed oxybutynin 2.5mg BD after being seen in Urology OPD.

SH: He lives alone since his wife passed away 8 years ago. He is a non smoker and drink 4 units of alcohol a week. There is no documented family history of note.

I tried to examine him but he told me, in quite rude terms, to go away so I didn’t persist. I hope you have better luck.

Thank you for your ongoing care

Dr D Tennant

The nurse manages to take some vital signs: 36.2 C, HR 80bpm, BP 135/70, RR 12 and CBG 5mmol/L and tells you Mr Vincent seems to be more co operative now and might let you examine him.

Question 1: In each body system – what common precipitants of delirium will you be looking for on examination? 

His temperature is 36.2, HR 80bpm, BP 135/70, RR 12 and CBG 5. His

Abbreviated Mental Test Score is 6/10 (losing points for recall, orientation and attention).

He appears agitated and is only able to follow one step commands but his speech appears normal. Cardiovascular and respiratory examinations are normal.

When you examine his abdomen, he has a fullness suprapubically with mild tenderness. This area is dull to percussion. Bowel sounds are normal and there are no hernias found.

It is difficult to perform a full neurological examination due to his agitation but there is no evidence of menigism, no evidence of head injury and the examination is grossly normal (including normal reflexes and downgoing plantars bilaterally). He is a bit unsteady on his feet but when prompted to use a zimmer frame is independently mobile.

Investigations:

Routine bloods sent on admission which are normal apart from a slightly raised ALP of 150IU/L and a slightly low corrected calcium of 2.10mmol/L.

Q2. What do the ECG and Chest x-ray show?

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Dr Sana Mufti, ST5 Geriatrics and General Medicine, Whipps Cross Hospital

For tips on following hashtags read more, and try one of our recommended Twitter plugins.

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