I Human Case Study: 55-
Year-Old Patient with
(Acute Confusion) (CLASS
6550) (Week #8)
CASE
Demographics
Age: 55 year old
Gender: Often Male (though varies)
Source: Usually brought in by spouse or adult child.
1. History of Present Illness (HPI)
, The key here is acute change from baseline. Family or caregiver usually provides the
history.
Onset: Sudden? Gradual over 24–48 hours?
Symptoms:
o Disorientation (time, place, person).
o Agitation or lethargy (fluctuating level of consciousness).
o Inability to perform activities of daily living (ADLs) that were previously manageable.
o Possible hallucinations (visual or auditory).
Associated Symptoms:
o Fever/chills: Indicates infection.
o Urinary symptoms: Dysuria, frequency, urgency, suprapubic pain (often absent in
elderly/confused patients).
o GI symptoms: Nausea, vomiting, diarrhea, or constipation (fecal impaction can cause
delirium).
o Head trauma: Any recent falls?
Review of Systems (ROS) – High Yield Positives:
o Neuro: No focal weakness (rules out CVA); no headache (rules out bleed/meningitis).
o Cardiac: Palpitations, chest pain (r/o arrhythmia or MI presenting atypically).
2. Past Medical History (PMH)
Common Comorbidities: Diabetes mellitus (risk for UTI/hypoglycemia), Hypertension,
Chronic Kidney Disease, Dementia (mild baseline—acute on chronic), Parkinson’s, or
previous CVA.
Surgeries: Recent surgery (within 3 months) is a red flag for nosocomial infection or
anesthesia-related delirium.
Medications: Crucial.
o New medications started recently?
o Anticholinergics (e.g., diphenhydramine, oxybutynin) – major cause of delirium.
o Benzodiazepines or opioids.
o Polypharmacy.
Year-Old Patient with
(Acute Confusion) (CLASS
6550) (Week #8)
CASE
Demographics
Age: 55 year old
Gender: Often Male (though varies)
Source: Usually brought in by spouse or adult child.
1. History of Present Illness (HPI)
, The key here is acute change from baseline. Family or caregiver usually provides the
history.
Onset: Sudden? Gradual over 24–48 hours?
Symptoms:
o Disorientation (time, place, person).
o Agitation or lethargy (fluctuating level of consciousness).
o Inability to perform activities of daily living (ADLs) that were previously manageable.
o Possible hallucinations (visual or auditory).
Associated Symptoms:
o Fever/chills: Indicates infection.
o Urinary symptoms: Dysuria, frequency, urgency, suprapubic pain (often absent in
elderly/confused patients).
o GI symptoms: Nausea, vomiting, diarrhea, or constipation (fecal impaction can cause
delirium).
o Head trauma: Any recent falls?
Review of Systems (ROS) – High Yield Positives:
o Neuro: No focal weakness (rules out CVA); no headache (rules out bleed/meningitis).
o Cardiac: Palpitations, chest pain (r/o arrhythmia or MI presenting atypically).
2. Past Medical History (PMH)
Common Comorbidities: Diabetes mellitus (risk for UTI/hypoglycemia), Hypertension,
Chronic Kidney Disease, Dementia (mild baseline—acute on chronic), Parkinson’s, or
previous CVA.
Surgeries: Recent surgery (within 3 months) is a red flag for nosocomial infection or
anesthesia-related delirium.
Medications: Crucial.
o New medications started recently?
o Anticholinergics (e.g., diphenhydramine, oxybutynin) – major cause of delirium.
o Benzodiazepines or opioids.
o Polypharmacy.
