Gerontology Case
An 82-year-old man recently returned to the long-term care facility after hospitalization for open reduction internal fixation of the right hip. He has been divorced for over 50 years and has two adult children who visit him frequently in the nursing home. He has a 5-year history of mild to moderate dementia and known urinary tract infections. His last recorded mini mental state examination (MMSE) registered 18, which was 3 months ago. While in the hospital, he did have an indwelling catheter for 4 days. He has been incontinent since his return to the hospital but the staff their attributes this to the catheter and his deconditioned state following hospitalization. His medications include donepezil, memantine, and acetaminophen for pain and fever as needed. He has no other known medical problems except a history of multiple urinary tract infections throughout his lifetime that, according to his son, have required extensive antibiotic treatment. He enjoys drinking regular coffee throughout the day, says it is a habit he has had since his days in the service years ago. His family members and the nursing staff report that he has been very restless and has been unable to use the urinal on time the past couple of days.
Vital signs: T 99°F, HR 80, RR 18, BP 128/78, BMI 22.
Chief Complaint: Foul smelling urine, incontinence, restless
Discuss the following:
1) What additional subjective data are you seeking to include past medical history, social, and relevant family history?
2) What additional objective data will you be assessing for?
3) What are the differential diagnoses that you are considering?
4) What laboratory tests will help you rule out some of the differential diagnoses?
5) What radiological examinations or additional diagnostic studies would you order?
6) What treatment and specific information about the prescription that you will give this patient?
7) What are the potential complications from the treatment ordered?
8) What additional laboratory tests might you consider ordering?
9) What additional patient teaching may be needed?
10) Will you be looking for a consult?
Sample Solution
- Past medical history: I would want to know more about the patient's history of urinary tract infections. What were the symptoms? How were they treated? Were there any complications?
- Social history: I would want to know about the patient's living situation. Does he live alone? Does he have help with his activities of daily living? Does he have a history of falls?
Full Answer Section
- Social history: I would want to know about the patient's living situation. Does he live alone? Does he have help with his activities of daily living? Does he have a history of falls?
- Relevant family history: I would want to know if there is a family history of urinary tract infections or other urological problems.
- Mental status: I would want to assess the patient's level of consciousness and orientation. I would also want to perform a mini-mental status examination (MMSE) to get a more accurate assessment of his cognitive function.
- Urinary system: I would want to assess the patient's urine for color, clarity, and odor. I would also want to assess the patient for any signs of urinary tract infection, such as fever, flank pain, or cloudy urine.
- Skin: I would want to assess the patient's skin for any signs of infection, such as redness, swelling, or warmth.
- Urinary tract infection: This is the most likely diagnosis, given the patient's history of urinary tract infections and the presence of foul-smelling urine.
- Dehydration: The patient has been incontinent since his return from the hospital, which could lead to dehydration.
- Medication side effect: The patient is taking donepezil and memantine, which can both cause urinary incontinence.
- Infection of the skin: The patient has a history of falls, which could have led to an infection of the skin.
- Urinalysis: This test will help to determine if the patient has a urinary tract infection.
- Complete blood count (CBC): This test will help to rule out dehydration and infection of the skin.
- Blood cultures: This test will help to rule out a systemic infection.