Case #1 Answers:
Answer 1
Problem list:
Acute
mental status changes, probable delirium
UGI bleeding
Dehydration with hypernatremia
Elevated BUN and Cre, ?pre-renal, ? Increased BUN secondary to UGI bleeding
Urinary tract infection
Likely
degenerative joint disease.
One could
create a long list of diagnostic possibilities but what seems most likely is
that Mrs. Walker is presenting with a delirium in the setting of an UGI bleed.
The UGI bleed may be caused by gastritis related to the use of Ibuprofen.
Although the delirium may have a number of causes, one would be
suspicious of the use of cimetidine.
Answer 2
Admit
Medicine
Diagnosis:
UGI bleeding, acute mental status changes
Condition
fair
Vital
signs q shift
Allergies:
Penicillin
IV:
the students should be questioned about the treatment of hypernatremia.
If Mrs. Walker shows evidence of volume depletion it would be
unreasonable to treat her initially with normal saline than switching to 1/2
normal once her volume status has been corrected.
It would
also be reasonable to transfuse Mrs. Walker with a Hct of 25.
The
remainder of the orders and management should focus on treating the upper GI
bleed, including starting a PPI, arranging for endoscopy, treating a urinary
tract infection and managing her
delirium.
The orders
for Mrs. Walker’s delirium should focus on minimizing interruptions,
encouraging a normal
sleep-wake cycle, and avoiding any medications that can make her confusion
worse. Benzodiazepines and
anticholinergics should be avoided.
Answer 3
Mrs.
Walker should have a full chemistry panel with LFT’s and calcium as well as a
TSH. I would obtain an emergent CT
scan as she has acute changes and has bruises. The
major concern would be a subdural
hematoma. The scan should be
obtained without contrast given the elevated BUN and creatinine.
Answer 4
Confusion
in an elderly person is first managed by providing an environment that does not
exacerbate confusion. Mrs. Walker
should be placed in a quiet room, her family allowed to stay with her (if they
are calming and do not make things worse!), and every effort made to allow her
to sleep at night but be awake during the day.
Restraints are quite frightening and often make people more confused.
Posey vests can be quite dangerous.
Restraints should only be used as a last resort when there is concern
that the person is likely to be hurt without the restraint or there is no other
way to maintain intravenous access.
In acute confusion, one can use a very low dose of a medication like
haloperidol, e.g. 0.5 mg, to take the edge off symptoms.
This should be used only when other measures have not worked and the
medication is needed for the person’s safety and comfort.
Haldol is not a benign medication.
It should not be used initially in large doses.
Answer 5
The key
information for the family is that Mrs. Walker is suffering from a delirium,
that it is most likely due to a medication she was taking and her acute illness,
and that, over time, it is most likely that she will recover fully.
Although it is extremely frightening for a family to see a mother
suddenly confused, they should be reassured and encouraged to help in calming
their family member.
Answer 6
Mrs.
Walker’s pre-morbid functional independence is the best prognostic information
one has. There is nothing to
indicate a pre-existing dementia or other problem.
Once the effects of the cimetidine wears off and the acute medical
problems are treated, Mrs. Walker should get better.
It can take a while, however, for a drug induced delirium to clear and
there may be a need for a brief stay in a nursing home for rehabilitation and
skilled care.