History:
- You are an FY2 in the emergency department.
- A 67-year-old female has presented with confusion in the morning and has been brought in by her daughter.
- She has a history of mild fever but no symptoms of chest infection or urinary tract infection, no history of dementia, and no additional symptoms or red flags.
- She has been diagnosed with depression and has been taking citalopram for 5 months.
- She also has hypertension and has been taking antihypertensive medication (bendroflumethiazide).
- Her daughter is in the cubicle and is very concerned about her mother.
- She has consent to talk about her mother.
Task:
- Talk to the daughter and address her concerns.
Examination and Investigations:
- Take observations and conduct a head-to-toe examination.
- Perform routine blood tests, liver function tests (LFT), kidney function tests (KFT), CT scan, and arterial blood gas (ABG).
- Findings: Blood tests show hyponatremia (120 mmol). The CT scan is normal, but CRP is high.
Concerns:
- What happened to her?
- Is she going to be alright?
Management:
- Greet, confirm identity, and ask about consent (don’t ask if it’s written in the stem).
- Take a focused history including red flags, risk factors (infections, fever, dementia, medical conditions, medications), ODPARA of tiredness, past medical history, and medication history.
- Perform ICE.
- Verbalize examination and investigation findings.
- Explain test results to the daughter, including hyponatremia and its relation to her mother’s presentation (low salt levels can cause confusion).
- Explain how her medications (citalopram and thiazide) could be the cause of low salt levels leading to confusion.
Management plan:
- She needs to be admitted, and fluids (3% NaCl infusion) will be given.
- As she is mildly feverish and has a high CRP, we need to rule out certain infections and will treat her accordingly.
- Involve a senior.
- Specialist referral and medication review will be done (changing citalopram to amitriptyline).
- Change thiazide to CCB (senior).
- Ask psychosocial questions and determine if she needs any support.