, i-Human Comprehensive Case Study: 55-Year-Old
Patient with Acute Confusion
Class 6550 – Week #8
Part 1: History Taking
Table 1.1 – Demographic & Presenting Problem
Variable Details
Patient Name Robert Coleman (fictional, representative case)
Age 55 years
Gender Male
Ethnicity African American
Chief Complaint (Collateral “He’s confused – doesn’t know where he is, saw him talking to himself,
source – wife) he tried to leave the house at 2 AM.”
Onset Acute – changed from baseline over 24–48 hours
Setting Emergency department (brought by wife)
, Table 1.2 – OPQRST for Acute Confusion (Collateral – Wife)
Question Wife’s Response
“Two days ago he was fine. Yesterday he forgot my name and couldn’t find the
Onset
bathroom.”
Provoking/Palliating Worse at night (sundowning), better when calm/familiar
Quality Disoriented to time/place; seeing “bugs on the wall” (visual hallucinations)
Region/Radiation Whole brain – global confusion
Severity “He’s not himself – I’m scared.” (Moderate–severe impairment)
Timing Acute over 1–2 days; no similar episode before
Table 1.3 – Collateral Past Medical History (PMH)
Condition Details
Type 2 diabetes Diagnosed 10 years ago; metformin 1000 mg BID
Hypertension Diagnosed 8 years ago; lisinopril 20 mg daily
Hyperlipidemia Atorvastatin 20 mg daily
Patient with Acute Confusion
Class 6550 – Week #8
Part 1: History Taking
Table 1.1 – Demographic & Presenting Problem
Variable Details
Patient Name Robert Coleman (fictional, representative case)
Age 55 years
Gender Male
Ethnicity African American
Chief Complaint (Collateral “He’s confused – doesn’t know where he is, saw him talking to himself,
source – wife) he tried to leave the house at 2 AM.”
Onset Acute – changed from baseline over 24–48 hours
Setting Emergency department (brought by wife)
, Table 1.2 – OPQRST for Acute Confusion (Collateral – Wife)
Question Wife’s Response
“Two days ago he was fine. Yesterday he forgot my name and couldn’t find the
Onset
bathroom.”
Provoking/Palliating Worse at night (sundowning), better when calm/familiar
Quality Disoriented to time/place; seeing “bugs on the wall” (visual hallucinations)
Region/Radiation Whole brain – global confusion
Severity “He’s not himself – I’m scared.” (Moderate–severe impairment)
Timing Acute over 1–2 days; no similar episode before
Table 1.3 – Collateral Past Medical History (PMH)
Condition Details
Type 2 diabetes Diagnosed 10 years ago; metformin 1000 mg BID
Hypertension Diagnosed 8 years ago; lisinopril 20 mg daily
Hyperlipidemia Atorvastatin 20 mg daily
