Case Studies

These case studies are presented for educational purposes only. They are not intended as medical advice.

CASE STUDY 1

Mrs. Hubley is brought to her family doctor’s office by her son.  They had been to the emergency department 2 nights ago when Mrs. Hubley fell while going to the washroom at night and fractured her shoulder.  She was able to call her son, who took her to the ED for xrays.  After a bit of a wait, she was given a sling to wear for the arm, a prescription for analgesics, and a follow-up appointment with orthopedics.  The ED doctor suggested that she go see her family doctor “in a few days”.

John (Mrs. Hubley’s son) is more than willing to take her to see her family doctor, as she doesn’t seem to be managing well at home.  She doesn’t seem to be eating right, her house is a mess, and he’s not sure that she’s changed her clothes since that night.  John can’t take care of her, as he works two jobs and is a single dad.

They arrive at the family doctor’s office and discover that the practice is being covered by a locum physician.  The new doctor takes a look at Mrs. Hubley’s chart before calling her into the office, but there isn’t much to read as she hasn’t needed to come in to see her doctor much.  He notices that she looks a little disheveled.  He asks a few questions about her fall and the ED visit.  She seems vague, distracted, and confused.  She is able to tell him that she lives alone, and this he finds concerning.

He decides to call John in to the office, because:

(a)    He wants to have a serious discussion about arranging urgent nursing home admission for Mrs. Hubley.

-OR-

(b)   He wants to ask how long she has been confused like this.

He picks “b” and finds out that John had had no concerns about his mom up until she fell and broke her shoulder.  He says that she was managing just fine, and was “sharper than I am”.  John wonders whether the pain medications may be too strong for her.

The doctor diagnoses DELIRIUM, takes a look at the pain meds, her other meds, and gives her a physical exam looking for potentially contributing causes to her acute confusion.  He has his nurse work with John to contact home care, to get some help for his mom while she is unable to use her right arm.  He prescribes regularly dosed plain Tylenol, and a reduced dose of the opioid analgesic which he counsels her to use judiciously.

At a follow up appointment 2 weeks later, she in no longer confused.  She still needs help for her personal care and housework, but hopes that the orthopedic consultant will let her use her arm again soon!

CASE STUDY 2

Mrs. Duncan is an 83 year old lady with hypertension, hypothyroidism, GERD, and osteoarthritis.  Her arthritis is fairly severe, causing her pain in the knees and hips when she walks.  She also has a bad shoulder.

She slipped on the ice taking out the garbage, and broke her hip.  Fortunately her neighbour saw her on the driveway and called the ambulance.  She underwent hip surgery successfully.

On the doctors’ rounds she is quiet and appears to be sleeping.  This is the routine for the first week postoperatively, and the doctor assumes that everything is on track for her recovery.  No complaints or problems are brought to the doctor’s attention.

HOWEVER

A closer look shows that Mrs. Duncan is drowsing away most of the day, everyday.  She occasionally wakes up and cries out, and her nurses have been assuming that she is having pain so are medicating her with opioids from the standing orders.  On postop day one when physio first got her out of bed it was documented that she was in quite a bit of pain.  Since then, she has been too sleepy to work with the physiotherapist.  Sometimes at night she is quite restless and even agitated.  Nursing has been giving her some analgesic to help get her to settle.

THIS IS HYPOACTIVE DELIRIUM

Sleeping all day everyday is not normal.  Hypoactive delirium is every bit as serious as hyperactive delirium, but sometimes under-recognized, as the patient is quiet on an individual visit, and thus may seem to be okay.  I would suspect overmedication in Mrs. Duncan, as the well-intentioned nurses have been interpreting her vocalizations as pain, and she likely does have some pain, but she appears to be overmedicated at present.  There could be another causative factor as well to account for her decreased level of consciousness and the agitation which is occasionally documented over night.  She might have a metabolic abnormality like dehydration, or a UTI or other infection.

On the next day, the doctor takes a closer look, and orders some blood work and a urinalysis.  He examines her and finds some abdominal tenderness.  A plain abdo film shows constipation, presumably from the opioids and inactivity.  She is too “out of it” for an MMSE.  The doctor orders a laxative, and reduces the amount of opioids she has on order, including the prn’s.  He orders regularly dosed acetaminophen as well.

The next day she is a little more awake, but confused and only scoring 16/30 on the MMSE.  The doctor asks the nurses to have her out of bed more, and the physio starts to work with her again.  Her bloodwork and urine are normal. By the end of the week her MMSE is up to 26/30.  She does have pain on starting to mobilize.  The doctor orders a low dose of hydromorphone to be given half an hour before her physiotherapy sessions.

Mrs. Duncan’s delirium clears and she recovers sufficient mobility to return home with supports.