82-YEAR-OLD FEMALE WITH DELIRIUM
SECONDARY TO URINARY TRACT INFECTION
IHUMAN CASE STUDY – HISTORY, PHYSICAL,
DIFFERENTIAL DIAGNOSIS, AND
MANAGEMENT PLAN
,PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
, Patient Bio Data
Name: Mr. R.K.
Age: 82 years
Gender: Male
Marital Status: Widower
Residence: Lives with daughter
Occupation: Retired farmer
Source: Daughter (HCPOA) - Patient is unable to provide
reliable history due to altered mental status.
Reliability: Patient is confused, agitated, and unreliable.
Daughter is reliable and provides collateral history.
Allergies: No Known Drug Allergies (NKDA) (Confirm with
daughter).
Medications:
o Lisinopril 10mg daily (HTN)
o Metformin 500mg BID (DM2)
o Atorvastatin 20mg daily (HLD)
o Levothyroxine 75mcg daily (Hypothyroidism)
o NEW MEDICATION? Ask daughter: "Has she started
any new medications in the last few weeks?"
(e.g., Benadryl, Tylenol PM, sleeping pills, pain meds,
antibiotics).
SECONDARY TO URINARY TRACT INFECTION
IHUMAN CASE STUDY – HISTORY, PHYSICAL,
DIFFERENTIAL DIAGNOSIS, AND
MANAGEMENT PLAN
,PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
, Patient Bio Data
Name: Mr. R.K.
Age: 82 years
Gender: Male
Marital Status: Widower
Residence: Lives with daughter
Occupation: Retired farmer
Source: Daughter (HCPOA) - Patient is unable to provide
reliable history due to altered mental status.
Reliability: Patient is confused, agitated, and unreliable.
Daughter is reliable and provides collateral history.
Allergies: No Known Drug Allergies (NKDA) (Confirm with
daughter).
Medications:
o Lisinopril 10mg daily (HTN)
o Metformin 500mg BID (DM2)
o Atorvastatin 20mg daily (HLD)
o Levothyroxine 75mcg daily (Hypothyroidism)
o NEW MEDICATION? Ask daughter: "Has she started
any new medications in the last few weeks?"
(e.g., Benadryl, Tylenol PM, sleeping pills, pain meds,
antibiotics).
