An 82-year-old man recently returned to the long-term care facility

Posted: April 4th, 2019

D4
Case 4
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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?

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D4 Case 4

Subjective Data

Chief Complaint: Foul smelling urine, incontinence, restless
Past Medical History: Mild to moderate dementia, multiple urinary tract infections, hip fracture
Social History: Divorced, two adult children
Family History: Unknown
Medications: Donepezil, memantine, acetaminophen
Allergies: None known
Objective Data

Vital signs: T 99°F, HR 80, RR 18, BP 128/78, BMI 22
Physical Exam: Genitourinary: Incontinent, foul smelling urine
Differential Diagnoses

Urinary tract infection
Bladder cancer
Prostate cancer
Renal calculi
Interstitial cystitis
Urethral stricture
Dehydration
Dementia
Delirium
Laboratory Tests

Urinalysis: Urine culture and sensitivity
Complete blood count (CBC)
Blood urea nitrogen (BUN) and creatinine
Electrolytes
Liver function tests
Radiological Examinations

Kidney, ureter, and bladder (KUB) X-ray
Renal ultrasound
Treatment

Antibiotics for urinary tract infection
Pain medication for pain
Fluid management for dehydration
Behavioral interventions for dementia
Environmental modifications for delirium
Potential Complications

Ascending infection
Pyelonephritis
Septicemia
Renal failure
Death
Additional Laboratory Tests

If the patient does not respond to antibiotics, additional laboratory tests may be ordered to rule out other causes of the infection, such as a kidney stone or prostatitis.
Additional Patient Teaching

The patient should be taught about the importance of drinking plenty of fluids, voiding regularly, and wiping from front to back after urination.
The patient should also be taught about the signs and symptoms of a urinary tract infection, such as foul smelling urine, pain or burning during urination, and frequent urination.
Consult

If the patient does not respond to treatment or has any complications, a consult with a urologist may be necessary.
References

Beers, M. H., Porter, R. S., Jones, T. V., & Kaplan, J. S. (2022). The Merck manual of diagnosis and therapy (19th ed.). Elsevier.
Fauci, A. S., Braunwald, E., Kasper, D. L., Hauser, S. L., Longo, D. L., Jameson, J. L., … & Fauci, A. S. (2022). Harrison’s principles of internal medicine (21st ed.). McGraw-Hill Education.