Posted: September 6th, 2023

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

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?

Submission Instructions:
• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
• Please post your initial response by 11:59 PM ET Thursday

Grading Rubric
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Your assignment will be graded according to the grading rubric.
Discussion Rubric
Criteria Ratings Points
Identification of Main Issues, Problems, and Concepts Distinguished – 5 points
Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts. Excellent – 4 points
Identifies and demonstrate an accomplished understanding of most of issues, problems, and concepts. Fair – 2 points
Identifies and demonstrate an acceptable understanding of most of issues, problems, and concepts. Poor – 1 point
Identifies and demonstrate an unacceptable understanding of most of issues, problems, and concepts. 5 points
Use of Citations, Writing Mechanics and APA Formatting Guidelines Distinguished – 3 points
Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors. Excellent – 2 points
Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors. Fair – 1 point
Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail. Poor – 0 points
Ineffectively uses the literature and other resources to inform their work. An unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention. 3 points

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.

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