WK3 CASE 2

FM&PH – Acute confusion

In module Family Medicine and Public Health

The case is based around Mrs Brenda Hall, a 77-year-old lady who is “off her legs” and confused.

MAIN CASE

Guidance and Resources – Acute confusion MED 35

Case Introduction – Acute confusion MED 35

Further Case Information – Acute confusion MED 35

Background Science – Acute confusion MED 35

Case Conclusion – Acute confusion MED 35

Formative Assessment – Acute confusion MED 35

CASE COMPONENT

Guidance and Resources – Acute confusion MED 35

In case FM&PH – Acute confusion

Learning Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

Highly recommended

· Polypharmacy is a common cause of morbidity, particularly in the elderly. Have a look at page 7 of this very useful document as to how you might perform a prescription review where someone is on multiple medications. This will also be helpful for your Logbook activities.

Resources

· Prescribing Handbook 1 and Prescribing Handbook 2 (iBook links)

· Patient.info: The Doctor’s bag

· Act FAST: Stroke Assessment Tool

· GMC guidelines for Capacity and Consent:

Consent: patients and doctors making decisions together

Consent guidance: Presumption of capacity

· The BMA toolkit for capacity is very useful

· Duties of a Doctor as set out by the GMC

· BMA Ethics Toolkit

CASE COMPONENT

Case Introduction – Acute confusion MED 35

In case FM&PH – Acute confusion

Mrs Brenda Hall is a 77-year-old lady who registered with the practice only a few weeks ago when she moved to a residential care home in the practice area. The care home has called the surgery this morning requesting a home visit because she is “off her legs” and confused. The receptionist taking the phone call has added Mrs Hall’s name to your GP Tutor’s home visit slot, which you are going to join your GP Tutor for.

A GP must be able to carry out a home visit without compromising patient safety. This includes having sufficient information available to make clinical decision making appropriate and safe. Typically a GP will take a printable summarised version of the patients medical notes, sometimes referred to as a ‘’Patient Summary’’ or “Transfer of Care” document. Although practices can make the content bespoke to their needs, typically the following information would be included:

· Patient name, age, address, phone number, emergency access details (e.g. key code entry), next of kin information

· Significant diagnoses*

· Repeat medications list and allergies

· Acute medications prescribed in the last 6 months

· Details of any consultations in the last 6 months

· Recent investigation results such as blood pressure, blood test results, imaging

*Whenever notes are entered onto the patient journal, anything of particular significance would need to be priority coded in order to appear on this list. If it is not coded as a priority item then it will not appear on the printed home visit summary. For example, hypertension and diabetes should be priority coded, whereas acute tonsillitis or tension headache would not be.

Before visiting, the GP would typically phone ahead. This is to gather more information and ensure that all the information and equipment is taken on the visit. Occasionally issues can be dealt with over the phone and do not require a visit. Alternatively, the GP can sometimes determine that the patient needs 997 ambulance rather than waiting for a visit, or can determine the clinical need of patients and prioritise visits. Some practices will have a dedicated triaging system for urgent appointments and home visits. This will involve a doctor or senior nurse conducting telephone triage to help filter urgent from less urgent problems.

In this case you may also want to know what type of care home Mrs Hall is in, as this will give you an idea of her care needs (residential or nursing, specialised dementia unit) as well as the level of training of the care staff (e.g. can they take blood samples?).

The receptionist has kindly printed off a transfer-of-care or patient summary document to take on the visit.

Have a look at that document, and match up the repeat medications to what conditions listed in Mrs Hall’s summary you think the medications are prescribed for.

It might be useful here to look at your Prescribing Skills Handbook 1: Performing a prescription review, and in Handbook 2: Prescribing in Elderly medicine.

IN PRACTICE:
Have a go at summarising a new patient’s notes. See what items in their medical history you would prioritise. Check with the member of staff who does notes summarising if your answers match.

The GP phones the residential home before the visit. He speaks to the manager called Stella. She tells you that Mrs Hall was slightly off her food yesterday, and then this morning didn’t want to get up as she said she felt ‘too ill’. She hasn’t been able to get much more history from here, as she seems quite muddled and ‘can’t really walk’. Stella says that Mrs Hall was saying to her that she needed to stay in bed as it ‘is the middle of the night’ when it was 9.30 in the morning. She is not usually confused.

The GP asks questions to check for medical emergencies which could be causing these symptoms. One medical emergency situation which the GP wanted to exclude was Transient Ischaemic Accident (TIA) and Stroke.

In this case, there are no features of stroke so the GP is happy that 997 does not need to be called immediately, and that you will go straight away.

Before you set off, the GP asks you to make sure you have everything you need for the visit.

The doctor’s bag

Equipment carried in a GP’s visit bag will vary depending on a number of factors (for example, rural vs urban, practice population demographics). The GP would also make sure that they take a phone with them, in case they need to summon help for themselves or their patient. The GP may also take some emergency drugs, although it is important to remember the practical issues such as storage requirements and shelf life, and it’s the GP’s responsibility to ensure the medications are in date so it can useful to set an alarm reminder on the computer system to review the contents at the next medication expiry date, or have systems within the practice where all the GP bags and medications are checked at regular intervals. Click on the link below for a really useful summary of what things to consider when setting up your visit bag:

Patient.info: Doctor’s Bag – Contents

You go to see Mrs Hall with the GP in the residential home, accompanied by Stella. Stella tells you in the staff office when you arrive that she is usually not confused and quite independent, and despite being unsteady on her feet she is able to mobilise with a zimmer frame. When you get to her room, Mrs Hall is sat on a chair with a blanket over her. She smiles when you and the GP come in, and says that she is happy for you to contribute to the consultation, saying, ‘You have to learn’.

You start with an open question about how she is feeling, to which she says ‘fine’. You ask her if she has any symptoms and she says ‘no thank you, I’m fine’. You outline that Stella has been worried about her, and ask Mrs Hall if she remembers telling Stella it was the night when it was the morning. Mrs Hall doesn’t seem to remember anything about it.

The GP outlines that this may be a case of acute confusion. When there are no definite other symptoms from a patient, it can be useful to consider a list of differentials and then ask questions to try to make some more or less likely, and then tailor your examination based on this information.

There are many possible diagnoses here. The GP suggests some questions to get more information to try to work out which is more or less likely. The GP asks Mrs Hall, checking answers with Stella

Have you had or have you got now any pain anywhere?

Why this question is important

This is important, as not only may localise a problem, but would also ensure that you could address this in the first instance, to attend to Mrs Hall’s comfort as your first concern.

Have you had any fevers?

Why this question is important

Good screening question to check for infective causes (but patients are not always aware if they have had raised temperatures).

Have you felt particularly cold?

Why this question is important

This might indicate fever, or might give a clue to hypothyroidism.

Have you had any problems with your waterworks? Noticed any changes to your wee?

Why this question is important

This for evidence to support urinary tract infection or urosepsis as a cause of confusion, and is a common presenting symptom of this underlying diagnosis.

Have you had any problems with your bowels or passing motions?

Why this question is important

This could give a clue to possible electrolyte imbalance, either due to a change in bowels (e.g. diarrhoea causing hypokalaemia) or as another associated symptom (e.g. hypercalcaemia). It might also highlight a thyroid disorder.

Have you had any trouble breathing, or a cough?

Why this question is important

This might indicate PE, a chest infection or pneumonia, all of which can be associated with confusion through hypoxia or sepsis.

Have you banged your head, or had any falls?

Why this question is important

Important to exclude intracranial bleed as the cause.

Have you had any problems with weakness of your arms or legs, or slurring of speech?

Why this question is important

Although the GP has asked Stella these questions this morning, it would be important to ask the patient herself in addition to ensure that intracranial causes such as stroke, bleed or encephalitis are not missed. Neurological symptoms could also indicate a B12 deficiency.

Have you felt as though you are aware of things that no-one else is? Have you been experiencing things that nobody else seems to be experiencing?

Why this question is important

These are example questions to check for psychosis, which could be on list of differentials in this case of acute confusion.

Have you been taking all your normal tablets as usual? Have you started anything new?

Why this question is important

These questions are to address possible overdose, either accidental or intentional, and discover if any new prescriptions have been issued which the GP might not be aware of e.g. from an Out-of-hours provider and the documentation has not yet reached the GP surgery, or over-the-counter. In this situation, Stella can corroborate any information about medications, but this might not be so easy if a person with confusion lives alone.

Have you been drinking more alcohol recently than normal?

Why this question is important

This is particularly important in this case, and might be a question that Mrs Hall may not immediately admit to. However, in a nursing home situation, this is less likely.

The only clue from the questions above is that Mrs Hall reports that her urine ‘smelt a bit last night’ and Stella reports that she had noticed that it was cloudy, but there was no blood.

The GP asks Mrs Hall’s consent to examine her, which she is agreeable to – holding out her arm first and telling you to ‘have a go at getting my blood pressure’.

The examination findings are:

· Temp 36.6 degrees Celcius (normal)

· Pulse 84bpm (normal)

· Sats 98% (normal)

· BP 112/62mmHg (normal)

· Heart sounds normal, chest clear, abdomen soft, non-tender.

· Able to move both arms and legs equally.

· No facial asymmetry.

· No slurring of speech, but clearly confused.

· She knew her name and date of birth, that she was ‘at the home’ but unable to say the name of the Residential Home. She did not know the time of day, nor day of the week but did know the month and year year. She was unable to recall an address, and was slow with spelling world backwards with several corrections. She could not recall the current prime minister.

The most likely cause of Mrs Hall’s symptoms

Urinary tract infection seems a likely possible cause of Mrs Hall’s symptoms. You ask Mrs Hall if she would be able to provide you with a urine sample. Unfortunately she is not able to produce one for the time that you are on the visit.

You have learnt about the diagnosis of UTI in case of Bladder cancer/Prostate disease. Remind yourself of this if you need to

The GP feels that there is strong clinical suspicion of UTI, so asks Stella to collect a sample when Mrs Hall is able, to send to the surgery to send off to the lab. The GP Tutor asks you to check the local antibiotic prescribing formulary and discover the recommendation for 3 days nitrofurantoin in your locality for uncomplicated urinary tract infection in women, which your GP tutor explains to the patient and Stella about taking.

The GP tutor also gives advice about what to do if Mrs Hall feels worse, or doesn’t seem to be improving over the next 48 hours as expected, in terms of herself or Stella calling the surgery for a further review, or NHS 111 if the surgery is closed. The GP also asks Stella to try to get the urine sample before the first dose of antibiotics and then call the surgery for the result in 3 days time.

IN PRACTICE:
Find the community antibiotic guidelines for your practice and see which antibiotics are used for the more common community infections (UTI, chest infection, cellulitis).

IN PRACTICE:
See how electronic prescriptions are generated. Does your GP use handwritten prescription pads ever? What happens on home visits?

2 days later

You notice a further home visit request for Mrs Hall on the GP computer system, and ask if you can accompany the GP Tutor again. You discover that Mrs Hall has not improved, and Stella reports that it has not been possible to collect a urine sample as Mrs Hall has become very unsteady on her feet and she has been more muddled.

You visit the residential home again with the GP. You find Mrs Hall sat in her chair, smiling. You ask her how she is feeling but she doesn’t seem to be able to understand you.

The GP tutor asks Mrs Hall about how she is feeling, but Mrs Hall says ‘fine’. She seems to be following the conversation and answering questions appropriately at times, although at times seems more confused, for example stating that ‘my daughter here (pointing at Stella who is not her daughter) has been looking after me very well’. There are no symptoms or observable signs to support any of the diagnoses considered the day before. Stella confirms that she was not like this the week before, and there was no handover from her previous residential home about this. Stella says that she has no family on her records.

The GP Tutor outlines that he is concerned about how confused and muddled Mrs Hall is, and that he would recommend hospital for further tests to try to work out why, so that this can be treated. Mrs Hall says nothing. The GP asks if Mrs Hall would be agreeable to hospital admission. However, it becomes increasingly clear that Mrs Hall is not able to understand, weigh up, retain or communicate her wishes regarding admission at this current time. She does not have capacity to make this decision at this time 

Often elderly patients will have a personalised care plan. This involves a planned discussion between the doctor and the patient (possibly with relatives and carers) about their health in general, but should include an assessment of their mental capacity and discussion about resuscitation and hospitalisation if they have an acute deterioration in their health. This care plan is kept with the patient and can be referred to in future by any medical staff the patient is happy to share the information with.

Here is a link to Mrs Hall’s care plan.

Take particular note of sub-sections not found in the transfer of care record:

· Advanced planning

· Emergency planning

· Risk assessments

Also the Mental Capacity Act is helpful to review at this point.

Further information about power of attorney can be found at Age UK

Further information on advanced decision (living will) is provided at NHS Choices.

Further information on advance statement is also provided at NHS Choices

IN PRACTICE:
Look at one patient summary or transfer of care document and familiarise yourself with the content and layout. Is there anything missing that you think should be included on there? Find out how this information is shared with other health care professionals (e.g. out of hours doctors, care homes, paramedics, hospital)

You see from the transfer of care document that Mrs Hall does not have a power of attorney nor advanced decision. However, she has made advanced statements that she would like, where possible, her care to be at the residential home, and that she would prefer not to be admitted to hospital, unless the situation were life-threatening.

Whilst reviewing the patient care summary, you notice Mrs Hall was given ibuprofen with omeprazole cover by another GP for her osteoarthritis a few weeks ago.

Mrs Hall consents to blood tests and the GP sends them to the lab marked ‘urgent’.

Further Case Information – Acute confusion MED 35

In case FM&PH – Acute confusion

Blood results

The blood result is phoned through to the GP surgery later that evening:

· Na 126 (133-145mmol/L)

· K 5.4 (3.5-5.4mmol/L)

· urea 7.5 (2.5-5.5mmol/L)

· creatinine 120 (50-90 ɲmol/L)

· FBC, Bone profile, LFT, TFT, CRP all normal

· Urine dipstick normal

The duty GP receives the result and arranges to visit Mrs Hall again that afternoon. He discusses the result and the option of hospital admission to monitor this, but she shakes her head. He has also seen in the notes the previous discussion this morning and her Care Plan.

IN PRACTICE:
How are urgent results dealt with in your GP Tutor’s practice? How is the result communicated from the lab?

The GP reviews all the notes and documentation regarding Mrs Hall’s condition and wishes, and considers that it is safe for Mrs Hall to remain at her Residential Home.

What treatment would you think would help Mrs Hall now?

What the GP decides to do

The GP decides to temporarily stop her omeprazole and ibuprofen. He suggests regular paracetamol instead. He arranges a repeat blood test for the next day with the community phlebotomist.

The next day, the blood results are back and Mrs Hall’s sodium is up to 128. This is reassuring and supports the working hypothesis. The GP initiates a telephone encounter with Mrs Hall’s carer, and Stella reports that she is doing well, and seems less confused. A further blood test is arranged, and the next day the sodium is 130. The GP visits and finds that Mrs Hall is much less confused. He asks if she has been troubled by any weight loss, cough, sputum, chest pain or haemoptysis; Mrs Hall has had none of these and her respiratory examination is normal. The GP is satisfied that SIADH is a less likely cause and decides that a chest xray is not indicated at this point. Her knee pain also seems controlled with the regular paracetamol. A further blood test is arranged for 4 days time after the weekend.

IN PRACTICE:
How are blood tests arranged in the community? How quickly can you get the results? How quickly can this

CASE COMPONENT

Background Science – Acute confusion MED 35

In case FM&PH – Acute confusion

Medications that are commonly used in general practice and cause hyponatraemia include ACE inhibitors, diuretics, anti-depressants, and proton pump inhibitors. Simply stopping the medications and cautiously re-introducing them or finding an alternative is the easiest way to manage this.

However, if medication is not the cause of hyponatraemia, the following flow chart is a useful way to investigate it further:

In your Prescribing handbooks, there is information about performing a prescription review (prescribing skills handbook 1) and prescribing in Elderly medicine (prescribing skills handbook 2)

Polypharmacy is a common cause of morbidity, particularly in the elderly. Have a look at page 7 of this very useful document as to how you might perform a prescription review where someone is on multiple medications.

CASE COMPONENT

Case Conclusion – Acute confusion MED 35

In case FM&PH – Acute confusion

The repeated blood tests reveal a normalised sodium. Stella reports that Mrs hall is back to her normal self. The GP adds a note to the patient record for ‘Adverse reaction to omeprazole: hyponatraemia’ so that if it is initiated in future, the GP would be alerted and could consider an alternative or arrange monitoring.

CASE COMPONENT

Formative Assessment – Acute confusion