J.B. is a 77-year-old man who is known to your practice. He is brought in today by his daughter, who reports a new onset of confusion accompanied by UI (first noticed bed was wet a few nights ago)

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J.B. is a 77-year-old man who is known to your practice. He is brought in today by his daughter, who reports a new onset of confusion accompanied by UI (first noticed bed was wet a few nights ago). When you see the patient today, he is oriented to place and person (knows you and your office), but not to time, and does not recall much about events of the past few days. He says that he is eating and drinking as usual (but the daughter is shaking her head to the contrary). He denies any change in bowel function, but is fearful of sleeping because he might “wet the bed.” The daughter states that he has been drinking a lot more water than usual and urinating more frequently. He denies any pain, other than arthritis. He was a regular attendee at the local senior center but has not been there for a week and seems to have forgotten about it.

Past medical history: Known CAD, hypertension, hyperlipidemia, impaired fasting glucose, osteoarthritis of knees.

Medications: Lisinopril 20 mg orally PO once daily in the evening; hydrochlorothiazide 12.5 mg PO once daily in the morning; metoprolol 50 mg PO once daily in the morning; simvastatin 20 mg PO once daily. OTC medications include Aleve, two tablets every 12 hours when needed for severe knee pain (infrequent use); topical Icy Hot for knee pain daily; glucosamine-chondroitin preparation daily for joint health; multivitamin for male more than 50 years daily.

Vital signs: Blood pressure (BP) 130/84 mm Hg; heart rate (HR) 60 beats per min, regular; respiratory rate 16 breaths/min; temperature 99.2°F orally; BMI 38.

Physical findings are unremarkable.

Questions

  1. What additional subjective data are you seeking?
  2. What additional objective data will you be assessing?
  3. What national guidelines are appropriate to consider?
  4. What tests will you order? How will you decide on prioritizing in this patient with multiple symptoms?
  5. What are the differential diagnoses that you are considering? For each one, map out your clinical

reasoning for and against it and make a tentative plan to confirm it or rule it out.

  1. Will you be looking for a consultation?

 

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