Dementia
Mr. Marshall is a 72 y/o male patient w/ moderate dementia who is present at the clinic w/ his wife for new onset of confusion that has gotten worse in the last 4 days ago. Mr. Marshall’s wife reports that he is unable to understand anything and has become restless. New symptoms include patients drifting off to sleep and having visual hallucinations. His symptoms are worse at night, and he was not able to recognize his wife last night. Another new symptom is urinary incontinence, requiring pt to wear a diaper. At this point, it is crucial to determine whether he is experiencing an acute delirium caused by an underlying infection. Differential diagnoses include urinary tract infection (UTI), pneumonia, and benign prostatic hyperplasia. Due to pt’s hx of COPD and tachypnea, pneumonia may be a possible diagnosis that needs to be ruled out. His new symptom of urinary incontinence makes BPH a possibility as Mr. Marshall has multiple risk factors including being a male and great than 70 years of age (Roehrborn, & Goueli, 2022). Urinary dipstick reveals UTI indicated by presence of leukocyte esterase and nitrites, ruling in UTI as the primary diagnosis.
To rule in UTI as the primary diagnosis, dipstick urine will be obtained first. Many clinics have the necessary tools to perform urinalysis, which can aid in immediate treatment. Urinalysis is also used as one of the first tests to determine whether patient has BPH (Roehrborn, & Goueli, 2022). Other tests for UTI include urine microscopy, urine culture, and gram stain (Benton, 2021). These tests will reveal presence of bacteria if any. Chest x-ray and CBC can be ordered to rule out pneumonia (Cilloniz, & Torres, 2022).
Mr. Marshall is experiencing acute delirium, which is placing a lot of stress on his wife. Due to his decreased cognitive ability and increased possibility of combativeness and uncooperative behavior, it will be best to hospitalize him. At the hospital, he will receive antibiotic therapy via IV of levofloxacin 500 mg q 24 hrs (Benton, 2021). The patient will receive IV therapy until he is stable enough to get discharged home. Once patient is stable enough, he will be sent home with oral antibiotic such as cephalexin 500 mg PO TID for approximately 7 days (Benton, 2021). Since Mr. Marshall was in the hospital for 2 days, he is to only take cephalexin for 5 days at home. Provide appropriate resources to Mrs. Marshall who is Mr. Marshall’s primary caregiver. This is a crucial part of the patient treatment plan as the caregiver’s fatigue can result in negative consequences for both. Resources include home health aides and homemakers who can offer brief breaks for the caregiver. Frequent reorientation and redirection can decrease confusion for the patient’s w/ dementia (Benton, 2021). Educate patients about the importance of performing ROM exercises that can enhance patient’s cognitive and sensory ability (Benton, 2021). Lastly, have the patient make an appointment at the clinic in a week for a follow up visit.
References
Benton, T. J. (2021, January 25). Urinary tract infections in men. Epocrates web. Retrieved June
17 from https://online.epocrates.com/diseases/76/Urinary-tract-infections-in-men
Centers for Medicare & Medicaid Services. (2015, October 15). ICD-10: Clinical concepts for
family practice.
Cilloniz, C., & Torres, A. (2022, May 31). Community-acquired pneumonia. Epocrates web.
Retrieved June 17 from
pneumonia-non-COVID-19
Roehrborn, C., & Goueli, R. (2022, January 26). Benign prostatic hyperplasia. Epocrates web.
Retrieved June 17 from https://online.epocrates.com/diseases/208/Benign-prostatic-
hyperplasia
Case Analysis Tool Worksheet
I. Epidemiology/Patient Profile
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Mr. Marshall is a 72 y/o retired school principal w/ Alzheimer dementia diagnosis since 4 years ago. His wife is his primary caregiver. Past neuropsychological testing revealed advanced dementia. Medical hx include HTN & COPD. Family hx include dementia. |
II. Prioritized Cues from Hx and PE
Tier 1Tier 2Tier 3
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Confusion – pt is a poor historian and is unable to answer questions himself |
Hx of smoking for 10 years – quit at age 30. |
Lives with wife |
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Pt is restless and much more confused since 4 days ago. |
No change in medication |
Have three children |
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Visual hallucinations |
Hx of HTN and COPD |
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Urinary incontinence for the past 4 days |
Family hx of dementia |
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Unable to perform ADL |
Age over 70 |
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Oriented to self only |
Male sex |
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Unable to cooperate w/ complicated exams |
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Does not respond to internal stimuli |
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MoCA score of 12/30 |
III. Problem Statement
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72 y/o male patient w/ moderate dementia present at the clinic w/ his wife for new onset of confusion that has gotten worse 4 days ago. Pt’s wife reports that he is unable to understand anything, and has become restless. Pt drifts off to sleep, and appears to be having a conversation with someone. His symptoms are worse at night, and he was not able to recognize his wife last night. New symptom includes urinary incontinence, requiring pt to wear a diaper. |
IV. Differential Diagnosis
Leading dx:
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Urinary tract infection ICD N39.0 (Benton, 2021). |
(Includes what rules-in the leading dx)
History Finding(s) Physical Exam Finding(s)
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Confusion – pt is a poor historian and is unable to answer questions himself |
Urinalysis Leukocyte esterase 2+ + Nitrites |
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Pt is restless and much more confused since 4 days ago. |
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Visual hallucinations |
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Urinary incontinence for the past 4 days |
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Unable to perform ADL |
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Oriented to self only |
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Unable to cooperate w/ complicated exams |
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Does not respond to internal stimuli |
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MoCA score of 12/30 |
Alternative dx:
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Pneumonia ICD J18.9 (Cilloniz, & Torres, 2022). |
History Finding(s) Physical Exam Finding(s)
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Confusion – pt is a poor historian and is unable to answer questions himself |
Chest x-ray: slight expansion of retrosternal space, showing mild hyperinflation |
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Pt is restless and much more confused since 4 days ago. |
tachypnea |
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Visual hallucinations |
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Urinary incontinence for the past 4 days |
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Unable to perform ADL |
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Oriented to self only |
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Unable to cooperate w/ complicated exams |
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Does not respond to internal stimuli |
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MoCA score of 12/30 |
Alternative dx:
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Benigh Prostatic Hyperplasia ICD N40.1 (Roehrborn, & Goueli, 2022). |
History Finding(s) Physical Exam Finding(s)
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Urinary incontinence for the past 4 days |
Post-void residual urine volume = 50 mL |
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Pt needs to wear a diaper |
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Male sex |
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Age over 70 |
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Confusion – pt is a poor historian and is unable to answer questions himself |
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Pt is restless and much more confused since 4 days ago. |
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Visual hallucinations |
V. Explanation of Diagnostic Plan (including tests, labs, imaging studies, etc.) and Treatment Plan in prioritized order:
Diagnostic PlanRationale
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Lab tests Urinalysis Urine culture Urine microscopy |
(See Essay Portion) |
Treatment PlanRationale
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Hospitalization |
(See Essay Portion) |
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Levofloxacin 500 mg IV q 24 hrs |
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Address caregiver stress -Provide resources |
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Discharge instructions Including antibiotic oral therapy Cephalexin 500 mg TID for 7 days |
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Frequent reorientation and redirection |
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Exercise – ROM exercises to enhance cognitive and sensory stimulation |
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