I’m feeling really confused lately. My family is worried about me.”
HPI: Pt states he is here for confusion x 3-4 days. States that he can’t seem to remember things and is having trouble understanding what people are saying. He states that he feels that his mind is foggy and that he can’t think clearly- it has been getting worse. He is not sure if anything makes it worse and states nothing makes it better. He says that it seems to be worse in the evening when he is tired.
Medications: Atenolol 50 mg daily
Allergies: NKDA
Medication Intolerances: none
Past Medical History: HTN Chronic Illnesses/Major traumas- none
Hospitalizations/Surgeries Vasectomy
Family History Mother alive with hypertension Father alive with type 1 diabetes Social History Admits to having a couple beers with dinner occasionally. Does not smoke or use illicit drugs
ROS Student to ask each of these questions to the patient: “Have you had any….”
General Denies weight change, fatigue, fever, chills, night sweats Cardiovascular Denies chest pain, palpitations, or edema. Denies’ hands and feet are feeling cold. Skin Denies delayed healing, rashes, bruising, bleeding or skin discolorations. Respiratory Discloses dyspnea Eyes Denies blurring or visual changes of any Gastrointestinal Denies abdominal pain, N/V/D,
kind constipation
Ears
Denies ear pain, hearing loss, ringing in ears, or discharge
Genitourinary/Gynecological
Discloses problems with urinating. States
that he frequently has to get up during the night to urinate and that it feels as if he is not emptying his bladder completely.
Nose/Mouth/Throat
Denies sinus pain, dysphagia, nose bleeds or throat pain
Musculoskeletal Denies back pain, joint swelling, stiffness or pain
Breast N/A
Neurological Denies syncope, transient paralysis, weakness, paresthesia’s, and black-out spells.
Heme/Lymph/Endo Denies night sweats, swollen glands, increase thirst, increase hunger, and cold
or heat intolerance
Psychiatric Denies depression, anxiety, or sleeping difficulties
OBJECTIVE
Weight 215 lbs BMI 29.2 Temp 37.1 C BP 150/78
Height 6’ 0” Pulse 80 Resp 16
General Appearance
Healthy-appearing adult male in no acute distress. Alert and oriented; answers questions appropriately.
Skin Not relevant
HEENT
Head is normocephalic, atraumatic, and without lesions. Eyes: PERRLA. EOMs intact.
Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation
bilaterally.
Gastrointestinal
BS active in all the four quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast N/A
Genitourinary Not relevant
Musculoskeletal Not relevant
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric Not relevant
Lab Tests
Albumin- 24 hour urine
CBC with dif
CMP 14
UA
Assessment
o Differential Diagnoses
o Acute Urinary Retention with Urosepsis
Rationale: Difficulty urinating, confusion, and respiratory distress may indicate
urosepsis. AQ’s urinary issues combined with confusion could be a sign of acute urinary
retention or a urinary tract infection that has spread to the bloodstream. Urosepsis can
lead to altered mental status and respiratory distress due to systemic inflammatory
response syndrome. This condition is common in older men with underlying prostate
issues such as benign prostatic hyperplasia (Lee & Kuo, 2022).
o Hypercapnic Respiratory Failure
Rationale: Difficulty breathing along with confusion could be due to hypercapnia, often
seen in patients with respiratory diseases such as COPD. In COPD exacerbations, airflow
obstruction and poor ventilation can lead to CO2 retention, resulting in respiratory
acidosis. Elevated CO2 levels in the blood can cause confusion, altered mental status, and
respiratory distress. Underlying lung disease or obesity could be risk factors to explore
(Villar et al., 2022).
o Hypoosmolar Hyponatremia
Rationale: Confusion, difficulty breathing, and urinary issues can also be seen in patients
with hyponatremia, especially when caused by SIADH. SIADH results in excessive
release of antidiuretic hormone, leading to water retention and hyponatremia. Symptoms
of hyponatremia include confusion, shortness of breath, and decreased urine output or
difficulty urinating (Szerlip, 2021).
o Final diagnosis: Acute altered mental status
Pathophysiology: AMS is a clinical presentation resulting from various
underlying conditions, and in this case, it could be caused by infections like urosepsis or
pneumonia, which can lead to sepsis-induced encephalopathy and confusion, along with
respiratory distress and urinary retention (Lee & Kuo, 2022). Respiratory failure due to
conditions such as COPD exacerbation or pulmonary embolism could cause hypoxia or
hypercapnia, resulting in confusion (Villar et al., 2022). Another possibility is electrolyte
imbalances, such as hyponatremia caused by conditions like SIADH, which can lead to
confusion, difficulty breathing, and urinary problems (Szerlip, 2021). Further diagnostic
work-up is needed to identify the underlying cause, including lab tests, imaging, and
clinical evaluation.
Plan
Medications: none
o Non-pharmacological recommandations: environnemental modifications,
reorientation techniques, maintaining sleep hygiene, family and caregiver support
o Diagnostic tests: further testing will need to be done in hospitals such as EKG,
CXR, CT scan, and possibly an EEG.
o Patient education: the patient and family should be educated about the importance
of prompt follow up in the emergency department for further testing.
o Culture considerations: In some cultures, discussing altered mental status openly
may be stigmatized. Sensitivity is needed when addressing the issue with the patient and
his family, particularly if there is fear of embarrassment or shame regarding cognitive
symptoms.
Health promotion: routine checkups, stress management, balanced diet, adequate
hydration
o Referrals- none
o Follow up- report to ED immediately
References
Lee, C. T., & Kuo, C. H. (2022). Urosepsis and its management in older adults. Geriatrics & Gerontology International, 22(3), 313- 319.
Villar, J., et al. (2022). Acute exacerbation of chronic obstructive pulmonary disease: Pathophysiology and management. Journal of Pulmonary and Respiratory Medicine, 12(5), 456-467.
Szerlip, H. M. (2021). Hyponatremia: Etiology and management. Endocrine Practice, 27(6), 634-646.
