APatientwithanAlteredMentalStatus Yourfirstweekonthemedicalservice,youareaskedtoassumethecareofan 88yearoldmanwhowasrecently admittedforableeding gastriculcer. Hewasa residentofanearbynursinghomeandhasalonghistoryofmultiplemedicalproblems includingcongestiveheartfailure, insulindependentdiabetes,chronicosteoarthritis, COPDwithexacerbationsofacutebronchitis,cerebrovasculardisease(hesustaineda mildthromboticlefthemisphericstroke5yearsago),dementia,Parkinsonsdisease, anddepression.

. He underwent endoscopy the day after admission, he had his ulcer lasered locallytostopthebleeding,andhewastransfusedtwounitsofPRBCtorestorehis hematocritto32%.Youarecalledbythenursingstaffbecausefamilymembersnoted that he has had the new onset of confusion and somnolence that have fluctuated throughouttheday. His medications include Lasix, Lisinopril, Digoxin, Insulin, Prednisone (20 mg/day),Sinemet,Haldol,andEffexor. P.E. reveals a thin elderly man who is awake but minimally responsive to questioningorstimuli.T100.2;P120irregirreg;R16;BP170/82;O2sat96%onroom air.SKINdrywithdecreasedturgorbutnorashorlesions.LNnonepalp.HEENT conjnormal;bilateralcataractspreventfundoscopy;oropharynxhasdrymucosabutno erythema;hewearsbilateralhearingaids.CHESTclear.CORJVP5cm.Irregirreg withvariableS1intensity,loudS2,nomurmursorrubs. ABDsoft;nomassesor hepatosplenomegaly. G/Rnormal;hemeneg;aFoleybladdercatheterisinplace. EXT no edema. NEURO minimally responsive and attentive to questions and stimulationwithdisorganizedansometimesincoherentspeech;cannotcooperatewith cranial nerve, motor, cerebellar exam; reflexes are diminished throughout; Babinski signsarenegative. LABS: Na149,K5.0,Cl109,HCO329,BUN60,Cr1.6,glu355 Hb11.0,Hct31.5,WBC9.2(normaldifferential),plts255K UA: clear;1.020;1+RBC,2+WBC;nocasts EKG: Irregirregabout120/min;QRSandQTintervalsarenl noSTTwavechangesnoted CXR (AP only): nl heart size/loss of diaphragm shadow behind the heartontheleftside.

QUESTIONS: 1. Doesthispatienthavedelirium?Whatbedsidefeaturessupportthisdiagnosis?

2.

Whataspectsofthispatientprediposehimtodelirium?

3.

Whatarepotentialprecipitatingcausesofdeliriumexistforthispatient?

4.

Arethereadditionaldiagnostictestsyouwouldorderatthistime?

5.

On the day of admission, the patients family asks you not to institute any heroicmeasures ifthepatientstopsbreathing orifhisheart stopsbeating. Theyindicatethathehassufferedenoughandthatheisnolongercompetent tomakedecisionsabouthismedicalcare.Howdoyourespond?

6.

Assuming that your management is successful, what measures can you recommendtodiminishthelikelihoodthatthisscenariowillrecur?