Reference no: EM133662654
Assignment
Past medical History
An 86-year-old man has been in a residential home for 3 years since his wife died. He was unable to look after himself at home because of some osteoarthritis in the hips limiting his mobility. Apart from his reduced mobility, which has restricted him to a few steps and a rather irritable temper when he doesn't get his own way, he has had no problems in residential care.
However, he has become much more difficult over the last 36 h. He has accused the staff of assaulting him and stealing his money. He has been trying to get out of his bed and his chair, and this has resulted in a number of falls. On some occasions his speech has been difficult to understand. He has become incontinent of urine over the last 24 h. Prior to this he had only a rare occasion of incontinence.
The covering AGACNP is called to see him and finds that he is rather sleepy. When aroused he seems frightened and verbally aggressive. He thinks that there is a conspiracy in the ward and that the staff are having secret meetings and planning to harm him. He is disorientated in place and time although reluctant to try to answer these questions.
Social History
He is a non-smoker and drinks 1-2 beers a month.
PMH/Meds
On a routine blood test 8 years ago he was diagnosed with hypothyroidism and thyroxine 100 mg daily is the only medication he is taking. The staff say that he has taken this regularly up to the last 36 h and his records show that his thyroid function was normal when it was checked 6 months earlier. The staff say that he is now too difficult to manage in the residential home. They feel that he has dementia and that the home is not an appropriate place for such patients.
Physical Exam
There is nothing abnormal to find apart from blood pressure of 178/102 mmHg and limitation of hip movement with pain and a little discomfort in the right loin.
Norm
Thyroxine 0.8 ng/dL 0.7 - 1.8 ng/dL
Thyroid-stimulating hormone 1.6 mU/L 0.3-6.0 mU/L
Fasting Blood glucose 100
Urine dipstick: - sugar, +protein, ++ blood
Task
A. Does this patient have dementia? Why or why not?
B. Would you want any other patient information, labor diagnostics at this time? If so what?
C. What are your top 3 differential diagnoses and why?
D. What is the most likely diagnosis?
E. What precipitated this problem?
F. How will you treat this patient and why?