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Mr. Wright
TRAINING MATERIALS for SP/CI
PRESENTING COMPLAINT: Urinary retention (“I can’t pee”)
DIAGNOSIS: Delirium in the setting of polypharmacy and urinary retention
PATIENT NAME: Bob Wright
PATIENT DEMOGRAPHICS:
Age 85
Sex: Male
Race: Caucasian or African American
PROFILE
Mr. Wright is an older man with many medical problems (diabetes, hypertension, chronic knee
pain, obesity, benign prostatic hypertrophy). He is in the Emergency Room on a Saturday
morning as a result of lower abdominal discomfort from not being able to urinate. He usually is
able to pee although he does have a slower stream and some hesitancy in starting his stream of
urine as a result of his enlarged prostate. He has not eaten breakfast yet and has not gotten any
food in the Emergency Room. Also, he has not taken his morning medications yet.
Mr. Wright is married to his second wife who is several years younger. They have no children
and in general enjoy watching old movies and going to antique stores. He worked as a
psychologist and in general has a good memory.
He is hard-of-hearing and usually wears hearing aids. He has not been sleeping well and has
been taking 1 or 2 Tylenol PM pills to help him sleep for the last week. He took a Tylenol PM
last night to help him sleep. He does not drink alcohol, smoke, or have any bad habits except for
eating lots of sweets.
OBJECTIVES FOR LEARNERS:
 To use the confusion assessment method to screen for delirium
 To consider alcohol withdrawal as a cause of delirium in an older adult
 To ask a patient’s caregiver about the patient’s baseline mental and functional status
when a patient has delirium
PRESENTATION:
Patient:
Mr. Wright should appear very drowsy and have trouble staying awake throughout the exam.
He says “What?” to most of questions because he can’t hear very well. He can answer some of
the questions correctly (knows the day of the week) but should not be able to pay attention to
lengthy questions, conversations, or detailed exams as he starts to doze off.
Goal: In general, Mr. Wright should be sleepy. He DOES NOT have disorganized thinking. He
has the other CAM features (inattention, acute onset/fluctuating course, and altered level of
consciousness—lethargy). He can answer briefly before disengaging and dozing off.
Opening line:
In response to the typical opening question from the learner, “What brings you to the hospital?”
The patient states, “I can’t pee!”
Questions to anticipate:
When was the last time you were able to urinate?
o Yesterday…
When was your last bowel movement?
o I think it was a few days ago.
Are you in pain?
o Just uncomfortable—I feel like my bladder is really full!
Family:
Mr. Wright’s wife believes Mr. Wright is sleepy because he has not been sleeping well. She
states that last night Mr. Wright took Tylenol PM, and since then he has been sleepy. In fact she
says, “He has been sleeping so soundly the last few nights that he has wet the bed! He has never
had trouble controlling his bladder before. And now he can’t urinate at all. I think he last went
to the bathroom seven or eight hours ago.”
Goal: The family member should assist in the interview while hanging back a bit so that the
physician has to ask some questions of Mr. Wright.
Questions to anticipate:
Has he been moving his bowels?
o He tends to get constipated and I think it has been a few days but I am not sure. Honey,
when was your last bowel movement?
Does he drink any alcohol?
o No, he gave that up years ago.
How is his memory?
o It’s pretty good for his age. I mean, he’ll forget some names or appointments if I don’t
remind him but he gets along fine.
How is his hearing?
o He can’t hear well without his hearing aids. Should I bring them in?
How are his blood sugars?
o They are usually pretty good. I noticed it was low this morning when they checked it.
He has not had anything to eat yet today.
Does he take his medications?
o He uses a pillbox to remember his meds and generally does well with it.
Has he been taking the pain medication/any other medications?
o He hasn’t been using the oxycodone as he hasn’t really had any problems with pain
lately. It’s been more a sleep issue. He just can’t fall asleep. He started to take Tylenol
PM a week ago and that’s been helping a lot. It makes him groggy during the day but he
feels like it’s worth it to be able to fall asleep.
o
Example questions to ask MD:
“What’s the plan?”
“Is there anything I can do to help?”
PROPS: IV, Gown
Patient appearance: Patient should appear to be an older adult (>65).
INFORMATION FOR LEARNERS:
Mr. Wright is an 85 year-old who presents to the Emergency Room due to abdominal discomfort
and an inability to urinate.
PAST MEDICAL HISTORY:
Obesity
Hard-of-hearing
Diabetes mellitus, type 2
Peripheral neuropathy
Gastroparesis with intermittent nausea
Hypertension
Depression
Gastroesophageal reflux disease
Hyperlipidemia
Benign prostatic hypertrophy
PAST SURGICAL HISTORY:
Appendectomy 1978
LATEST VITALS:
TM 37.1 BP 188/84 HR 66 RR 18
LABS:
Na+
K+
BUN
Cr
Glucose
Patient’s Labs
140
4
45
1.9
55
MEDICATIONS:
Tylenol PM nightly for the last week
Insulin NPH 10 units BID
Lisinopril 40 mg q day
Citalopram 40 mg q day
Metoprolol 25 mg po BID
Flomax 0.4 mg po q day
Ref Range
135-145 mmol/L
3.5-5 mmol/L
7-21mg/dL
0.8-1.2 mg/dL
65-179 mg/dL
Aspirin 81 mg q day
Percocet 5/325 as needed for pain (has not needed)
Reglan 10 mg po TID
Amlodipine 10 mg po q day
Simvastatin 40 mg po q day
Omeprazole 40 mg po q day
Gabapentin 600 mg po TID
Phenergan 25 mg as needed for nausea (has not needed)
You have 10 minutes to interview the patient. After 10 minutes, you will work with your
team to document your diagnoses and orders.
You do NOT need to perform a physical exam as part of this exercise.
SPECIFIC SUGGESTIONS FOR FACILITATOR FEEDBACK SESSION FOR MR.
WRIGHT
What is your diagnosis? Delirium
Is the patient CAM positive, why or why not? YES, Acute onset/change from baseline, inattention, altered
level of consciousness
What are 3 predisposing factors for delirium? hearing impairment, depression, multiple medications,
several of which are anticholinergic and/or centrally-acting
What are 3 precipitating factors for delirium?
urinary retention, anticholinergic medication (Tylenol PM), constipation, possible CO2 retention,
hypoglycemia, sensory deprivation (not wearing hearing aids)
What is your management plan?
Control his blood pressure
Treat hypoglycemia
Evaluate for retention (bladder scan, catheter)
Consider fecal impaction
Hold sedating medications (gabapentin, reglan, phenergan, percocet, Tylenol PM)
Put in hearing aids
Suggested Reading for Additional Training:
Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165. Accessed 11/26/12 at
http://www.nejm.org/doi/full/10.1056/NEJMra052321
This excellent review article includes information on the Confusion Assessment Method, the relationship
between delirium and dementia, and the appropriate management of delirium.
The American Geriatrics Society 2012 Beers Criteria Expert Panel. Update The American Geriatrics
Society Updated Beers Criteria for Potentially Inappropriate Medication Use in the Elderly. JAGS April
2012. Accessed 11/26/12 at
http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
This article includes the list of medications to avoid in older adult patients.